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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/dentalpathologypOOabbo 


DENTAL 


Pathology  AND  Practice 


BY 


FRANK  ABBOTT,  M.D., 

Professor  of  Dental  Histology,  Surgery,  and  Therapeutics,  in  the  New  York  College 
of  Dentistry,  etc.,  etc. 


With  Ninety-Seven  Illustrations. 


PHILADELPHIA : 

The  S.  S.  White  Dental  Manufacturing  Co. 

1896. 


Copyright,  1896,  by  Frank  Abbott. 


PREFACE. 


To  undertake  the  preparation  of  a  work  which  should,  even 
approximately,  exhaust  the  topics  embraced  in  the  title  of  this  vol- 
ume would  be  a  task  far  beyond  my  intention  or  even  desire.  Such 
an  exhaustive  treatise  would  assume  proportions  which  would  dis- 
courage any  but  the  most  ardent  student  in  dental  surgery.  I  have 
therefore  aimed  simply  to  present,  as  concisely  as  possible,  the  most 
common  and  important  pathological  conditions  found  in  the  oral 
cavity,  with  the  treatment  in  each  condition  which  has  proven  most 
satisfactory  in  a  practice  extending  through  a  long  series  of  years. 

Again,  in  the  great  mass  of  material  pertinent  to  the  subject  in 
hand,  with  which  I  find  myself  confronted,  much  is  of  the  highest 
importance  to  every  student  in  our  specialty  ;  but  on  the  other  hand, 
much  more  is  of  a  character  which  in  my  judgment  it  would  be  a 
waste  of  time  and  energy  to  attempt  to  embody  in  an  intentionally 
limited  work  such  as  I  have  set  before  me.  I  have  found  also  that 
the  selection  from  this  great  mass  of  that  which  I  deem  most  essen- 
tial to  our  special  branch  of  practice  is  a  task  of  no  small  magnitude. 
If  I  have  so  solved  the  difficulties  that  this  little  volume  shall  prove 
of  service  to  the  student  and  practitioner  of  dental  surgery,  I  shall 
ask  for  no  greater  gratification. 

By  the  kind  permission  of  my  friend.  Dr.  Bodecker,  I  have  used 
three  cuts  taken  from  his  work,  "  Dental  Anatomy  and  Pathology," 
to  illustrate  the  first  chapter,  for  which  he  has  my  warmest  thanks. 

I  take  this  occasion  to  express  my  great  admiration  and  friend- 
ship for  my  faithful  and  honest  instructor  in  histology  for  so  many 
years,  Dr.  Carl  Heitzmann.  The  great  assistance  he  has  always  so 
cheerfully  rendered  in  my  studies  and  in  the  illustration  of  the  several 
papers  I  have  had  the  honor  of  presenting  to  the  professional  and  sci- 
entific world,  I  shall  always  remember  with  the  kindest  of  feelings. 

F.  A. 


CONTENTS. 


CHAPTER  I.  PAGE 

Synopsis  of  the  Development  of  Teeth i 

CHAPTER  II. 
Odontoblasts  in  their  relation  to  Developing  Dentine    .        ,        5 

CHAPTER  III. 
Growth  of  Enamel 15 

CHAPTER  IV. 
Teeth  of  the  Lower  Jaw  at  Birth 28 

CHAPTER  V. 
Congenital  Defects  in  Enamel 46 

CHAPTER  VI. 
Studies  of  the  Pathology  of  Enamel  of  Human  Teeth,  with 

special  reference  to  the  Etiology  of  Caries        •        •        •      57 

CHAPTER  VII. 
Caries  of  Human  Teeth 70 

CHAPTER  VIII. 
Children's  Teeth  and  their  Treatment  .        .        .        .        .        .90 

CHAPTER  IX. 

Microscopical  Studies  upon  the  Absorption  of  the  Roots  of 

Temporary  Teeth     . 94 

CHAPTER  X. 
Filling  Teeth 102 

CHAPTER  XL 
Exposed  Pulps  in  Teeth,  and  their  Treatment      .        .        .        .114 

CHAPTER  XIL 

Treatment  of  Pulpless  Teeth 118 

vii 


Vlll  .  CONTENTS. 

CHAPTER  XIII.  PAGE 

Alveolar  Abscess 121 

CHAPTER  XIV. 
Diseases   of   the   Antrum   due  to    Dental   Complications,  and 

THEIR  Treatment 127 

CHAPTER  XV. 
Abscesses  in  the  Salivary  Glands 135 

CHAPTER  XVI. 
Salivary  Calculus  and  Pyorrhea  Alveolaris         ....     136 

CHAPTER  XVII. 
Facial  Neuralgia 143 

CHAPTER  XVIII. 
Hyperostosis  of  Roots  of  Teeth 169 

CHAPTER   XIX. 

Conditions  of  Patients  during  which   Severe   Dental  Opera- 
tions SHOULD  BE  Avoided 187 

CHAPTER  XX. 
Stomatitis  :  Varieties,  Causes,  and  Treatment       ....     191 

CHAPTER  XXI. 
Contributions  to  the  Knowledge  of  Tumors  of  the  Jaws         .     193 

CHAPTER  XXII. 
Senile  Atrophy  of  the  Upper  Jaw 225 


DENTAL  PATHOLOGY  AND  PRACTICE. 


CHAPTER    I.      , 

SYNOPSIS  OF  THE  DEVELOPMENT  OF  TEETH. 

Development  of  the  teeth  is,  to  most  histologists,  of  all-ab- 
sorbing interest.  Its  study  has  occupied  the  time  and  most  earnest 
research  of  the  foremost  observers  for  the  past  thirty  or  more  years. 
The  latest  writers  upon  this  subject,  Heitzmann  and  Bodecker 
(Bodecker's  "Anatomy  and  Pathology  of  the  Teeth"),  have  so  mi- 
nutely and  satisfactorily  cleared  the  subject  up  that  I  propose  to  con- 


FlG.  I. 


Transverse  Section  of  Furrow  on  Lower  Jaw  of  a  Human  Emeryo  Six  Weeks  Old. 
E,  epithelium  of  oral  mucosa  ;   T,  tongue  ;   V,  blood-vessels  ;  B,  base  of  oral  cavity  ;  F,  furrow 
in  transverse  section.     Magnified  75  diameters. 

fine  this  short  chapter  to  the  essential  features  of  the  process,  and 
refer  the  student  to  that  work  for  the  details  of  .this  useful,  not  to  say 
necessary  study. 

At  the  sixth  week  of  intra-uterine  life,  a  slight  furrow  in  the  gum 
may  be  observed  extending  the  entire  length  of  the  future  alveolus, 


2  DENTAL  PATHOLOGY  AND  PRACTICE. 

along  which  there  shortly  appears  a  row  of  hillocks  in  "the  epithelium, 
as  it  grows  into  the  future  jaw.  This  hillocked  epithelial  depression 
is  the  so-called  primitive  dental  groove.  (Fig.  i.)  It  will  shortly 
be  observed  that  this  groove  has  penetrated  in  the  form  of  a  tube  to 
a  considerable  depth,  being  known  at  this  stage  as  the  enamel-cord. 
As  development  proceeds  it  forms  the  enamel-organ  of  each  tooth. 
This  tube  or  enamel-cord,   and   future  enamel-organ,   is  lined  with 


Fig.  2. 


BE 


Epithelial  Cord  terminating  in  the  Future  Enamel-Organ  of  a  Human  Embryo 

Three  Months  Old. 
O,  stratified  epithelium  of  the  orai  cavity;  Co,  epithelial  cord  of  the  enamel-organ  ;  6",  short 
secondary  offshoot  of  the  epithelial  cord  ;  SP,  broad  secondary  offshoot  of  the  epithelial  cord  ; 
^fi',  external  or  outer  epithelium;  E  (lower),  internal  or  inner  epithelium  ;  Af,  medullary- tissue 
sprung  from  previous  epithelia,  the  future  stellate  reticulum  ;  P,  dentine-papilla ;  Ca,  capsule  or 
tooth-sac;  E  (upper),  embryonal  tissue,  the  future  fibrous  connective  tissue  of  the  mucous 
membrane.     Magnified  75  diameters. 

epithelium  of  the  same  character  as  the  covering  of  the  mucous  mem- 
brane from  which  it  sprung.  About  the  third  month  this  cord  widens 
at  its  distal,  or  deepest  end,  assuming  the  shape  of  a  shallow  cup.  (See 
Fig.  2.)  At  this  period  (the  third  month)  the  first  trace  of  the  dentinal 
papilla  is  observable.  By  the  end  of  the  third  month,  or  the  beginning 
of  the  fourth,  changes  in  the  development  have  taken  place,  so  that  the 
following  formations  are  distinguishable  :  i,  the  external  epithelium  ; 
2,    the   internal    epithelium ;    3,   the   stratum    intermedium  ;    4,   the 


SYNOPSIS    OF   THE    DEVELOPMENT   OF   TEETH.  3 

stellate  reticulum  ;  and  5,  the  lateral  cord  for  the  enamel-organ  of 
the  permanent  tooth.  (See  Fig.  3.)  The  tooth-sac  at  this  period  has 
commenced  its  growth  from  the  papilla,  which  gradually  encircles  the 

Fig.  3. 


Epithelial    Cord  terminating  in  the  Enamel-Organ  of  a  Human  Embryo  Fivh 

Months  Old. 

O,  stratified  epithelium  of  the  oral  cavity  ;  SP,  secondary  offshoot  of  the  epithelial  cord ;  Co, 
epithelial  cord  of  the  enamel-organ  ;  M,  myxomatous  tissue  of  the  enamel-organ  ;  EE,  external 
or  outer  epithelium;  IE,  internal  or  inner  epithelium  ;  /,  stratum  intermedium,  bet\veen)inner 
epithelium  and  myxomatous  tissue  ;  P,  papilla;  O2,  capsule  or  tooth-sac;  /^,  fibrous  connective 
tissue  of  oral  mucosa.     Magnified  75  diameters. 

enamel-organ.  "  About  the  fifth  month  the  external  epithelium  of 
the  enamel-organ,  together  with  the  epithelial  cord,  begins  to  break 
up  into  epithelial  nests  and  buds,  amid  which   a  profuse  formation 


4  DENTAL   PATHOLOGY   AND    PRACTICE. 

of  red  blood-corpuscles  and  blood-vessels  takes  place." — Bodecker. 
At  about  this  time  also,  it  is  seen  that  the  internal  epithelium  is  under- 
going a  change  consisting  of  the  apparent  prolongation  of  the  single 
epithelia  into  what  is  termed  the  ameloblast  layer.  The  elongations 
upon  the  periphery  of  the  papilla,  which  are  observed  to  be  forming 
at  the  same  time,  are  termed  the  odontoblasts.  Between  the  first- 
formed  ameloblasts  and  odontoblasts  there  is  but  slight  space.  As 
development  progresses,  however,  the  dentine  forming  from  the  per- 
iphery of  the  papilla  toward  the  center,  and  the  enamel  from  the 
papilla  toward  the  surface,  they  gradually  separate,  the  enamel  and 
dentine  as  formed  being  joined.  During  the  fifth  month  the  first  for- 
mation of  dentine  takes  place,  and  about  one  month  later  that  of  the 
enamel. 

Before  calcification  begins  in  either  the  dentine  or  enamel,  the 
odontoblasts  and  ameloblasts  at  their  proximal  ends  are  seen  to  have 
broken  up  into  medullary  corpuscles,  in  which  condition  they  become 
infiltrated  with  lime-salts.  These  medullary  corpuscles,  as  well  as  the 
odontoblasts  themselves,  are  interconnected  by  means  of  very  delicate 
threads  of  living  matter,  which  in  the  formed  tooth  are  preserved  as 
Tomes  fibers  in  the  canaliculi,  and  Bodecker's  cross-lines  of  living 
matter,  connecting  Tomes  fibers  one  with  another. 

It  will  be  observed  from  the  foregoing  that  ameloblasts  and 
odontoblasts  are  not  direct  formers  of  the  respective  tissues,  enamel 
and  dentine,  but  are  present  simply  as  provisional  steps  in  their 
development.  A  constant  supply  of  medullary  corpuscles  to  the 
distal  ends  of  the  ameloblasts  is  furnished  from  the  stratum  inter- 
medium as  those  at  their  proximal  ends  become  infiltrated  with 
lime-salts,  the  deficiency  thus  caused  in  the  stratum  intermedium 
being  made  good  from  the  medullary  elements  of  the  stellate  reticulum. 
The  same  process  is  carried  on  in  the  demand  and  supply  of  the 
odontoblasts  ;  their  proximal  ends  are  furnished  with  medullary 
corpuscles  from  those  congregated  immediately  beneath  them,  as 
those  at  their  distal  or  peripheral  ends  become  calcified,  and  the 
supply  to  the  congregated  mass  is  furnished  from  the  body  of  the 
papilla.  As  the  medullary  corpuscles  become  calcified,  the  identity 
of  each  is  preserved  in  the  developed  tooth,  in  what  appears  in  both 
the  enamel  and  dentine  as  irregular-shaped  blocks,  the  canaliculi  and 
cross-lines  running  between  them  and  forming  their  boundaries. 

The  cementum  is  formed,  after  the  dentine  of  the  root  is  fully 
developed,  from  the  tooth-sac  and  the  periosteum  which  now  lines  the 
socket. 


ODONTOBLASTS   AND    DEVELOPING    DENTINE.  5 

CHAPTER   II. 

ODONTOBLASTS  IN  THEIR  RELATION  TO  DEVELOPING  DENTINE.* 

After  Virchow,  in  1850,  announced  his  belief  that  the  inter- 
cellular or  basis-substance  in  all  varieties  of  connective  tissue,  which 
he  termed  "  connective-tissue  substances,"  was  a  product  of  secre- 
tion, many  histologists  adopted  this  view  ;  and  to-day  we  meet  with 
publications,  both  in  English  and  German,  holding  fast  to  this  se- 
cretion theory.  It  is,  it  must  be  admitted,  apparently  the  simplest 
of  all  theories,  since  it  suggests  merely  that,  at  a  stated  period  of  its 
existence,  a  cell  should  give  out,  from  its  contents,  a  certain  quantity 
of  liquid,  which  eventually  might  become  solidified,  and  even  receive 
the  lime-salts,  forming  the  hard  tissues  such  as  bone,  dentine,  etc. 

Fortunately,  in  1861,  the  studies  of  the  late  Max  Schultze  showed 
that  all  intercellular  or  basement  substances  are  products  of  the  cells, 
inasmuch  as  a  certain  number  of  such  cells  would  die,  be  transformed 
by  a  chemical  process — not  fully  understood — into  a  glue-yielding 
substance  ;  whereas  a  certain  other  number  of  the  cells  would  remain 
unchanged,  and  represent  what  have  been  called  bone-cells,  cartilage- 
cells,  or  in  a  general  way  connective-tissue  cells. 

An  intermediate  position  between  these  two  extreme  views  was 
taken  in  i860  by  Beale,  who  claimed  that  the  intercellular  substance 
is  a  product  of  the  transformation  of  the  peripheral  portion  of  the 
cell.  Thus,  an  original  large  cell  might,  at  its  periphery,  be  con- 
verted into  glue,  or,  as  Beale  calls  it,  "formed  material,"  while  the 
central  portion  would  remain  forming  or  living  material,  much 
reduced  in  size,  and  now  termed  a  "connective-tissue  cell."  This 
latter  view  is  still  held  by  Klein,  of  London. 

It  was  in  the  basis-substance  of  cartilage  that  Fuerstenberg,  some 
fifty-two  years  ago,  by  chemical  treatment,  discovered  lines  of  de- 
markation  between  cartilage-cells,  which  Virchow  afterward  baptized 
"  territories."  Obviously,  territory  means  a  central  cell  with  a  given 
amount  of  surrounding  basis-substance.  According  to  those  who 
hold  to  the  secretion  theory,  the  quantity  of  basis-substance  around 
the  cell  would  be  entirely  a  product  of  secretion  of  the  central  cell. 
Originally,  in  the  embryo,  the  cells  lay  closely  packed  together,  and, 
once  having  begun  to  exude  the  intercellular  substance,  became 
pushed  apart,  and  eventually  widely  separated  from  one  another,  as  is 
seen  in  fully- developed  cartilaginous  tissue.  According  to  Beale,  the 
entire  territory  was  originally  a  large  cell  which  in  time  became  much 
reduced  by  the  solidification  of  its  peripheral  portion. 

*  Abbott,  Dental  Cosmos,  1888. 


6  DENTAL   PATHOLOGY   AND    PRACTICE. 

Max  Schultze  claimed  that  the  territory  was  originally  proto- 
plasm, or  composed  of  a  group  of  embryonal  or  indifferent  cor- 
puscles, the  peripheral  portion  of  the  protoplasm,  or  the  embryonal 
cells,  becoming  transformed  into  a  glue-yielding  basis-substance  ; 
during  which  process  they  became  deprived  of  life,  the  central  por- 
tion only  remaining  alive  and  retaining  its  shape  as  a  cell.  This  is 
the  theory  held  to-day  by  most  advanced  histologists,  and  which  the 
writer  considers  in  its  main  features  correct. 

In  contradistinction  to  the  "secretion  theory,"  this  has  received 
the  name  of  the  "transformation  theory."  In  1873,  C.  Heitzmann 
added  a  feature  of  importance  to  Schultze' s  transformation  theory. 
After  having  demonstrated  that  the  basis-substance  was  not  alto- 
gether devoid  of  life,  but  traversed  by  a  net-work  of  living  matter 
(a  view  which  was  afterward  corroborated  by  S.  Strieker,  of  Vienna, 
and  recently  by  other  observers  of  eminence),  he  arrived  at  the 
following  conclusions  concerning  the  development  of  a  territory  : 
A  territory  was  originally  protoplasm,  or  made  up  of  a  number 
of  protoplasmic  bodies,  the  so-called  embryonal  or  indifferent  ele- 
ments. Protoplasm,  wherever  found,  is  traversed  by  a  reticulum 
of  living  matter  ;  and,  since  embryonal  corpuscles  are  proto- 
plasm, they  are  interconnected  by  delicate  offshoots  of  living  matter, 
which  establishes  a  continuous  net-work  throughout  the  territory. 
Whenever,  in  the  process  of  development  of  a  territory,  its  peripheral 
portions  are  converted  into  glue-yielding  basis-substance,  the  con- 
tents of  the  meshes  alone  are  chemically  altered,  while  the  reticulum 
itself  remains  intact. 

According  to  this  idea,  a  liquefaction  of  the  contents  of  the  meshes 
only  is  required,  in  order  to  convert  an  already  formed  basis- 
substance  into  protoplasm  again.  Such  alternation  between  proto- 
plasm and  basis-substance  is  invariably  observed  in  the  development 
of  hard  tissues  ;  the  territories  becoming,  after  &ch  return  to  the  em- 
bryonal or  protoplasmic  condition,  more  perfect,  more  solid,  and  more 
regular,  as  is  seen  especially  in  the  development  of  cartilage  and  bone. 

Let  us  now  apply  the  view  here  advanced  to  developing  dentine, 
a  tissue  which  may  be  considered  as  a  highly  perfected  one,  surpass- 
ing in  its  individuality  and  refinement  of  structure  any  of  the  ordi- 
nary osseous  formations.  In  the  dentine  itself  there  are  no  cells  ; 
all  we  see  is  the  fibers  of  living  matter,  the  tenants  of  the  canaliculi, 
and  their  offshoots  passing  into  the  basis-substance.  The  main  mass 
is  not  cartilaginous,  as  was  formerly  supposed,  but  glue-yielding, 
especially  dense  and  indestructible  immediately  around  the  canaliculi, 
and  infiltrated  with  lime-salts.  The  only  formations  deserving  of  the 
term  "cells"  are  the  odontoblasts,  those  peculiar,  elongated  bodies 
(of  a  shape  and  size  to  remind  one  of  columnar  epithelia)  usually  seen 


ODONTOBLASTS    AND    DEVELOPING    DENTINE.  7 

at  the  periphery  of  the  papilla  in  developing,  and  at  the  periphery  of 
the  pulp-tissue  in  developed  teeth. 

These  peculiar  protoplasmic  bodies  send  offshoots  upward  into  the 
dentine  (the  dentinal  fibers), — offshoots  connecting  laterally  one  with 
another, — and  other  offshoots  downward,  uniting  them  with  the 
medullary  elements  of  the  papilla. 

The  first  to  see  and  describe  all  these  offshoots  was  Franz  Boll,  in 
1868,  and  he  was  corroborated  by  Waldeyer,  in  1869.  Before  these 
offshoots  were  observed,  attempts  at  explaining  the  formation  of  den- 
tine were  made,  first  by  A.  Kolliker,  in  1852,  in  his  handbook  of  his- 
tology. On  page  385  he  says,  "  In  the  formation  of  dentine  not  the 
whole  pulp  is  concerned,  but  only  its  outermost  layer  of  epithelium- 
like cells,  which,  by  a  continual  prolongation  of  the  original  cells, 
under  a  conthiuous  7nultiplication  of  the  nuclei,  apparently  keep  up  the 
same  thickness. 

"  I  am  not  willing  to  maintain  that  one  and  the  same  cell  is  suffi- 
'cient  for  the  whole  duration  of  the  formation  of  dentine,  for  I  con- 
sider it  as  quite  possible  that,  from  time  to  time,  the  dentine-cells  are 
replaced  by  others  forming  at  their  inner  side.  What  I  deny  is,  that 
the  whole  pulp  is  transformed  and  ossified  from  without  inward. ' ' 

Kolliker,  at  that  time,  knew  nothing  about  the  pr^esence  of  dentinal 
fibers.  In  order  to  explain  the  formation  of  the  dentinal  canaliculi  he 
(page  386)  discusses  the  following  three  possibilities  : 

I  St.  The  canaliculi  are  the  remnants  of  the  cavities  of  the  dentinal 
cells,  which,  in  the  process  of  ossification,  become  thickened  and 
hardened  in  their  walls,  but  are  not  perfectly  closed. 

2d.  The  canaliculi  originate  from  the  nuclei  of  the  dentinal  cells, 
which  elongate  and  coalesce,  but  retain  their  central  cavities. 

3d.  The  canaliculi  are  produced  by  a  process  of  resorption  in  the 
previously  homogeneous  dentinal  tissue,  in  a  manner  analogous  to 
the  formation  of  the  Haversian  canals,  or  the  canaliculi  in  the 
cementum. 

Of  these  three  possible  methods  for  the  formation  of  the  main  canali- 
culi, Kolliker  considered  the  first  as  the  most  probable,  and  was  con- 
vinced that  the  third  suggestion  alone  could  explain  the  origin  of  the 
fine  branching  canaliculi.  He  distinctly  states  that  no  other  tissue  is 
concerned  in  the  production  of  dentine  but  the  cells  which  were  later 
dubbed  odontoblasts,  and  that  these,  by  a  successive  taking  up  of  the 
lime-salts,  become  dentine.  He,  therefore,  as  early  as  1852,  although 
upholding  the  secretion  theory  so  far  as  bone-formation  is  concerned, 
unswervingly  from  that  time  up  to  date,  adopted,  for  explaining  the 
formation  of  dentine,  the  opposite  or  transformation  theory.  About 
ten  years  later  he  and  John  Tomes  discovered  the  dentinal  fibers, 
and,  with  their  acknowledged  presence  within  the  canaliculi,  and  their 


8  DENTAL  PATHOLOGY  AND  PRACTICE. 

connection  with  the  odontoblasts,  the  difficulties  of  explaining  the  for- 
mation of  dentine  by  the  secretion  theory  were  increased  considerably. 

Are  the  dentinal  fibers  remnants  of  the  central  portion  of  the 
odontoblasts,  whose  lateral  portions  become  transformed  into  basis- 
substance  ?  Are  the  dentinal  fibers  formed  between  the  odontoblasts, 
after  the  latter  have  become  basis-substance  ?  So  great,  indeed, 
seemed  the  puzzle,  that  in  1888  R.  R.  Andrews  deemed  it  advisable 
to  reiterate  a  previously  expressed  opinion  of  E.  Klein  and  others, 
that  there  are  two  sets  of  odontoblasts,  some  with  broad  bases  which 
become  basis-substance  altogether,  and  others  pear-  or  spindle-shaped, 
with  long  projections,  which  become  the  dentinal  fibers.  These  latter 
they  termed  "fibril-cells." 

It  would  seem  to  require  but  a  very  limited  amount  of  histological 
or  microscopical  experience  to  satisfy  oneself  of  the  untenableness 
of  these  views,  as,  with  a  comparatively  low  power,  projections  may 
be  seen  running  from  every  odontoblast  into  the  canaliculi  of  the 
formed  dentine,  some  giving  off  one,  some  two,  some  three  ;  and 
even  as  many  as  five  offshoots  have  been  seen  arising  from  a  very 
broad  end  of  an  odontoblast,  and  penetrating  the  canaliculi.  The 
"  fibril-cells,"  therefore,  are  nothing  but  narrow  wedge-shaped  odon- 
toblasts between  those  with  a  broad  base,  and  are  especially  numerous 
where  the  periphery  of  the  papilla  forms  a  sharp  curvature,  as  in  the 
pointed  cusps. 

After  eight  years'  study  of  this  subject,  Bodecker  and  Heitzmann 
announced  in  1887  that  the  odontoblasts  are  not  direct  dentine- 
formers;  that  they  break  up  into  embryonal  or  medullary  corpuscles 
shortly  before  the  appearance  of  the  basis-substance,  which  at  first 
appears  without  lime-salts  ;  and  that  the  dentinal  fibers,  which  were 
originally  in  connection  with  the  odontoblasts,  of  whatever  shape, 
after  the  breaking  up  of  the  latter  into  embryonal  corpuscles,  find 
place  between  these,  and  so  remain  in  their  respective  canaliculi,  even 
after  the  calcification  of  the  dentine  is  accomplished. 

From  personal  studies  I  am  fully  convinced  of  the  correctness  of 
this  position.  Unquestionably  there  are  places  in  a  developing  tooth 
where  the  odontoblasts  lie  unbroken  against  the  formed  dentine,  a 
condition  which  may  be  considered  as  a  state  of  rest  for  the  time 
being.  Far  more  frequently,  we  see  the  odontoblasts  split  up  into 
smaller  portions  of  protoplasm  which  we  term  medullary  or  embryonal 
elements,  and  wherever  this  is  the  case  the  fibrils  are  seen  passing 
into  the  already  formed  basis-substance  of  dentine,  between  the  rows 
of  embryonal  corpuscles.  This  explains  why  the  living  matter 
present  in  the  medullary  corpuscles  remains  unaltered,  even  after 
the  formation  of  the  glue-yielding  basis-substance,  and  its  infiltra- 
tion with  lime-salts.     It  explains,  further,  why  the  dentine,  after  the 


ODONTOBLASTS   AND    DEVELOPING    DENTINE.  9 

liquefaction  of  the  basis-substance,  in  pathological  conditions,  breaks 
up  into  medullary  or  inflammatory  corpuscles,  a  fact  that  I  observed 
in  the  process  of  caries  of  living  dentine  and  first  described  in  1879,  and 
which  was  later  corroborated  by  Bodecker  in  his  studies  upon  ebonitis. 

Several  questions,  however,  require  close  attention  in  the  history  of 
the  development  of  dentine.  One  of  these  is,  Are  the  odontoblasts 
absolutely  necessary  as  a  pre-stage  to  the  forming  of  dentine  ?  And 
secondly,  How  is  it  that  the  odontoblasts  produce  a  continuous  mass 
of  dentine  from  the  periphery  to  the  pulp,  if  they  are  converted  into 
basis-substance  in  layers  ?  For  we  know  that  dentine  is  stratified 
only  in  exceptional  cases,  and  one  would  expect  that  such  lines  of 
stratification  would  be  of  common  occurrence  if  one  row  of  odonto- 
blasts after  another  were  converted  into  basis-substance. 

To  the  first  question  I  am  unable  to  give  a  positive  answer,  but 
take  it  for  granted  that  they  are.  We  often  see,  at  the  summit  of  the 
papilla,  medullary  tissue  bordering  the  already  formed  dentine  with- 
out a  trace  of  odontoblasts.  Through  the  researches  of  John  Tomes, 
we  understand  that  odontoblasts  originate  by  coalescence  of  medul- 
lary corpuscles  of  the  papillary  tissue  ;  and  we  know,  furthermore, 
that  odontoblasts  again  return  to  the  medullary  condition  before  be- 
coming infiltrated  with  lime-salts.  It  appears  possible  that  previous 
odontoblasts  have  been  transformed  into  medullary  tissue,  and  that  no 
new  ones  had  been  produced  at  that  particular  period. 

To  the  second  question,  whether  or  not  the  odontoblasts  form  a 
single  row  for  the  time  being,  thus  involving  an  interruption  in  the 
appearance  of  the  basis-substance  of  the  dentine,  a  positive  answer 
can  be  given,  in  accord  with  the  observations  of  Kolliker  in  1852, 
above  quoted.  The  difference  between  his  view  and  that  here 
advocated  is,  however,  sufficiently  marked  to  demand  attention. 

He  claims  that  there  is  but  one  row  of  odontoblasts  capable  of 
producing  dentine,  and  that  these  become  continuous  by  a  prolifera- 
tion of  the  nuclei  of  the  original  single  row,  and  their  elongation 
thereby.  He  distinctly  denies  that  the  pulp  as  a  whole  could  be 
converted,  layer  after  layer,  into  odontoblasts.  John  Tomes,  on  the 
contrary,  holds  that  the  medullary  corpuscles  of  the  papillary  tissue 
are  progressively  converted  into  odontoblasts,  which  explains  the  fact 
that,  with  the  advancing  growth  of  the  dentine,  the  bulk  of  the 
papilla  diminishes.  With  the  last  the  view  which  I  support  agrees, 
but  with  this  addition,  viz,  that  each  odontoblast,  zuhile  being  reduced 
to  medullary  corpuscles  at  its  distal  or  peripheral  end,  is  being  added 
to  by  an  attachnent  of  jnedullary  corpuscles  of  the  papillary  tissue  at 
its  proximal  or  central  end. 

Undoubtedly  there  are  periods  of  comparative  rest,  in  which  a  fully- 
developed  odontoblast  appears  in  contact  with  the  dentine,  and  pene- 


lO 


DENTAL  PATHOLOGY  AND  PRACTICE. 


trates  into  the  papillary  tissue  with  sharply-defined  contours,  with  its 
narrow  and  pointed  end.  As  soon,  however,  as  the  building  of  den- 
tine is  resumed,  the  peripheral  end  of  the  odontoblast  is  seen  to  have 


Fig.  4. 


DG\ 


Tooth  of  a  Pig's  Fetus,  10  Centimhteks  Long. 
D,  D,  calcified  dentine;    DC,  non-calcified   dentine;    O,  row  of  odontoblasts,  partly  fully 
formed,' partly  forming;  Af,  odontoblasts  broken  up  into  medullary  corpuscles  in  the  process  of 
formation  of  dentine  ;  P,  vascularized  myxomatous  tissue  of  papilla.     Magnified  200  diameters. 


ODONTOBLASTS    AND    DEVELOPING    DENTINE. 


become  divided  into  medullary  bodies  again,  and,  simultaneously. 
of  medullary  corpuscles  are  superadded  to  the  opposite  or  central 

Fig.  5. 


rows 
end. 


DM 


Tooth  of  a  Pig's  Fetus,  10  Centimeters  Long. 
Z>,  £>,  calcified  dentine  ;  £>C,  non-calcified  dentine:  £>M,  dentine  in  the  process  of  formation 
from  medullar)-  corpuscles;  O,  odontoblasts  in  multiple  rows,  with  spindle-shaped  elements 
wedged  in  between  the  broad  odontoblasts ;  71/,  medullary  corpuscles  produced  from  odonto- 
blasts ;  such  corpuscles  also  attached  to  the  distal  ends  of  the  odontoblasts.  Magnified  800 
diameters. 


12 


DENTAL    PATHOLOGY    AND    PRACTICE. 


A  beautiful  illustration  of  this  process  may  be  seen  in  the  developing- 
tooth  of  a  pig's  fetus,  ten  centimeters  long.     (See  Fig.  4.)    Here  we 

Fig.  6. 


Tooth  of  a  Human  Fetus,  Six  Months. 
D,  D,  calcified  and  stratified  dentine;  DC,  DC,  non-calcified  dentine,  the  border  of  the  cal- 
cified dentine  being  marked  by  globular  formations ;  O,  odontoblasts  splitting  into  medullary 
corpuscles  toward  the  dentine,  and  showing  rows  of  such  corpuscles  at  the  distal  ends  ;  M, 
medullary  corpuscles  ready  for  transformation  into  basis-substance  of  dentine  ;  P,  P,  myxoma- 
tous tissue  of  papilla.     Magnified  400  diameters. 


ODONTOBLASTS   AND    DEVELOPING    DENTINE.  1 3 

see  several  rows  of  odontoblasts,  bordering  the  non-calcified  portion 
of  the  basis-substance  of  the  dentine.  At  that  portion  in  which  un- 
changed odontoblasts  stand  against  the  dentine,  others,  likewise 
fully  developed,  are  attached  to  the  uppermost  row.  This  we  may 
consider  to  be  in  a  condition  of  comparative  rest.  At  that  portion,  on 
the  contrary,  in  which  the  odontoblasts  are  replaced  by  medullary  cor- 
puscles toward  the  dentine,  without  a  distinct  boundary-line  between 
the  two,  we  see  rows  of  medullary  corpuscles  attached  to  the  inner 
ends  of  the  odontoblasts,  whereby  the  transverse  diameter  of  the 
odontoblastic  layer  is  noticeably  broadened.  In  the  former  instance, 
the  layer  of  odontoblasts  is  fairly  well  marked  toward  the  papillary 
tissue  ;  in  the  latter  instance  it  is  indistinct,  the  odontoblasts  blending 
with  the  papillary  tissue. 

High  powers  of  the  microscope  illustrate  still  better  this  claim. 
(See  Fig.  5.)  With  these  it  becomes  evident  that  the  dentinal 
fibers,  originally  attached  to  and  connected  with  the  odontoblasts, 
are  placed  between  the  medullary  corpuscles  as  soon  as  the  former 
are  converted  into  the  latter.  Wherever  we  find  rows  of  medullary 
corpuscles  at  the  inner  ends  of  the  odontoblasts,  delicate  fibrillae  are 
seen  coursing  between  their  rows  or  groups. 

Since,  according  to  the  views  which  I  hold,  the  myxomatous  basis- 
substance  of  the  papillary  tissue  is  supplied  with  living  matter,  the  same 
as  are  the  so-called  cells,  there  is  no  difficulty  in  explaining  the  origin 
of  new  protoplasmic  bodies  from  the  previous  myxomatous  basis- 
substance,  for  the  purpose  of  supplying  continuous  additions  to  the 
odontoblasts. 

The  facts  just  described  are  well  illustrated  in  the  developing 
teeth  of  a  human  fetus  from  six  to  seven  months  old.  (See  Fig.  6.) 
The  cusp  of  the  dentine  shows  stratification,  although  no  odonto- 
blasts are  seen  at  the  summit  of  the  papilla.  At  the  sides  of  the  cusps, 
odontoblasts  appear,  broken  up  into  finely  granular  medullary  cor- 
puscles toward  the  non-calcified  basis-substance  of  the  dentine,  and 
augmented  in  their  bulk  by  rows  of  glistening,  almost  homogeneous, 
medullary  corpuscles,  toward  the  papillary  tissue.  Occasionally  we 
meet  with  a  basis-substance  of  dentine  not  yet  calcified,  and  still 
exhibiting  its  composition  of  medullary  corpuscles.     (See  Fig.  7.) 

Upon  studying  this  specimen,  all  doubts  as  to  the  origin  of  the 
basis-substance  of  the  dentine  must  vanish.  All  previous  attempts 
at  explaining  how  the  odontoblasts  are  converted  into  dentine  must 
prove  futile  in  the  face  of  such  a  specimen.  Although  admitting 
that  such  a  plain  example  is  seen  only  exceptionally,  this  specimen 
seemed  to  be  so  instructive  and  so  convincing  that  the  illustration 
with  a  very  high  power  was  made.  With  the  facts  advanced,  a  hitherto 
mooted  question  seems  to  have  found  solution. 


14 


DENTAL   PATHOLOGY   AND    PRACTICE. 


As  to  the  question  why  dentine  in  all  its  stages  of  development 
appears  to  be  a  continuous  mass,  and  but  exceptionally  interrupted 

Fig.  7. 


Tooth  of  Human  F^tus,  Seven  Months. 
D,D,  dentine  calcified  ;  DC,  non-calcified  basis-substance  of  dentine,  close  above  the  caoil- 
lary  b.ood-vessels,  broadened  and  visibly  n.ade  up  of  medullary  corpuscles ;  C,  cap  Hary  b  ood- 
vessel  m  transverse  and  longitudinal  section  ;  M,  M,  medullary  corpuscles    eady  fo     nfi'trltron 

Tdln.   h,"?     r":/^""'  '^^'  ™^dullary  corpuscles  arranged  in  rows  for  the  format  on  of 
odontoblasts.     Magnified  800  diameters.  uimaiion  01 


GROWTH    OF    ENAMEL.  I5 

by  marks  of  stratification,  the  explanation  is  that  the  odontoblasts 
themselves  are  continuous.  ^Not  that  the  original  odontoblasts  are 
preserved  and  augmented  from  the  periphery  toward  the  center  ;  but 
that  so  much  of  an  odontoblast  as  is  converted  into  dentine  at  its 
peripheral  portion,  is  made  good  by  the  addition  of  medullary  cor- 
puscles at  the  central  end  or  portion,  from  the  tissue  of  the  papilla, 
both  the  protoplasmic  bodies  and  the  basis-substance. 


CHAPTER    III. 

GROWTH    OF    ENAMEL. 


Many  acute  and  conscientious  observers  have  exhausted  their  talent 
in  attempting  to  reveal  the  mysteries  surrounding  the  development 
of  the  dental  tissues.  For  all  such  honest  attempts  we  should  be  most 
grateful,  for  they  serve  as  stepping-stones  enabling  us  to  reach  a  height 
which  renders  the  history  of  the  development  of  these  organs  fairly 
intelligible.  Our  modern  researches  have  conclusively  settled  the 
fact  that  the  laws  governing  the  formation  of  dental  tissues  are  the 
same  as  those  controlling  all  other  tissues  of  the  animal  body.  The 
stumbling-block  has  always  been  the  method  of  development  of 
enamel.  For  many  years  histologists  have  agreed  that  enamel  is 
originally  an  epithelial  formation,  and  consequently  to  be  considered 
as  a  dermal  or  tegumentary  appendage,  as  Todd  and  Bowman,  in 
their  celebrated  cyclopedia  (1848-49),  termed  it.  Still,  the  result  of 
metamorphosis  of  the  epithelia  was  known  to  be  the  stellate  reticulum, 
which  closely  resembles  myxomatous  connective  tissue.  All  observers 
heretofore  have  shrunk,  on  merely  theoretical  grounds,  from  the  idea 
that  epithelium  could  ever  give  rise  to  connective  tissue.  The  idea 
that  it  must,  under  all  circumstances,  produce  epithelial  derivations 
exclusively  has  apparently  served  as  an  insurmountable  obstacle  to  the 
full  understanding  of  the  development  of  enamel. 

How  could  brilliant  thinkers  be  satisfied  that  a  single  row  of  cells, 
supposedly  epithelial  in  nature,  would  give  rise  to  a  heavy  layer  of 
enamel,  such  as  exists  on  the  crowns  of  temporary  teeth  at  the  time 
of  eruption  ?  What  is  the  function  of  the  stellate  reticulum, — a 
rather  heavy  layer  of  tissue,  so  notable  for  its  beautiful  structure  ?  Is 
there  any  satisfaction  in  the  idea  that  this  enamel-organ  should  serve 
merely  for  the  nutrition  of  the  enamel,  or,  as  others  have  it,  for  pro- 
tection, in  the  shape  of  a  soft  gelatinous  cushion,  against  injuries  to 

*  Abbott,  Dental  Cosmos,  1889. 


l6  DENTAL    PATHOLOGY    AND    PRACTICE. 

the  enamel  from  without  ?  It  sounded  almost  like  a  revelation  when 
G.  Hertz,  in  1866,  had  the  courage  to  assert  and  maintain  that  the 
stellate  reticulum  contributes  directly  to  the  formation  of  the  enamel 
through  a  new  formation  of  cells.  The  mistaken  conception  that 
the  sum  total  of  what  we  term  odontoblasts  was  to  be  considered  as  a 
membrane  known  as  the  "  membrana  eboris,"  and  the  sum  total  of 
what  we  call  ameloblasts  as  a  membrane  termed  "  membrana  adaman- 
tina,"  wrought  havoc  in  the  minds  of  many  histologists. 

The  secretion  theory  was  one  of  the  outgrowths  of  this  membrane 
theory.     A  few  good  men,  I  am  sorry  to  say,  still  cling  to  it. 

A.  Kolliker,  in  his  "Handbook  of  Histology  of  Man"  (1852), 
speaks  of  development  of  enamel  in  the  following  terms  :  ' '  The  de- 
velopment of  the  dental  substances  has  always  been  considered  a  very 
difficult  topic.  The  relations  are  the  simplest  in  the  enamel,  and 
not  the  slightest  doubt  prevails  that  the  enamel-cells,  by  a  complete 
calcification,  become  transformed  into  enamel-fibers  (enamel-rods). 
As  soon  as  a  small  portion  of  the  cells,  without  any  preliminary 
deposition  of  lime  particles,  begins  to  ossify,  we  recognize  a  small 
lamella  of  enamel  over  the  somewhat  larger  dentine-cap,  which  has 
also  recently  originated.  The  deposition  of  lime  proceeds  in  the 
cells  from  within  outward  till  they  are  at  last  transformed  into 
enamel-fibers  and  simultaneously  transgress  on  new  cells,  by  which 
means  the  layer  of  enamel  is  broadened.  While  this  is  going  on  the 
enamel-membrane  has  not  disappeared  at  the  place  where  the  ossifi- 
cation started.  On  the  contrary,  we  find  this  membrane  always 
of  the  same  breadth  so  long  as  the  deposition  of  the  enamel  lasts, 
which  proves  that  the  ossified  portion  of  the  membrane  is  con- 
tinuously being  replaced  by  an  additional  mass.  Apparently  this  is 
done,  not  by  the  production  of  new  cells,  but  by  a  continuous  out- 
growth of  the  original  ones.  The  enamel-organ  (stellate  reticulum) 
is  certainly  of  great  importance  in  the  building  up  of  enamel,  and 
owing  to  its  richness  in  albumen  and  a  gelatinous  mass  in  its  meshes 
is,  so  to  speak,  a  pantry  from  which  the  enamel-membrane  derives 
the  material  for  its  growth,  being  at  some  distance  from  the  blood- 
vessels. In  fact,  we  see  this  spongy  tissue  losing  in  its  bulk  during 
the  development  of  enamel,  and  finally  disappearing  when  the  forma- 
tion of  enamel  is  completed." 

I  will  here  add  that  to  Kolliker  the  enamel-membrane  means  a 
layer  of  epithelia.  He  describes  the  enamel-organ  as  being  made  up 
of  anastomosing  star-shaped  cells,  or  a  reticular  connective  tissue, 
which  contains  in  its  meshes  a  large  amount  of  albumen  and  a  liquid 
rich  in  mucus.  The  same  author,  in  his  work  on  the  "  History  of 
Development  of  Man  and  the  Higher  Animals,"  in  1879,  claims  that 
the  stellate  reticulum  of  the  enamel-organ  is  identical  in  appearance 


GROWTH    OF    ENAMEL.  I7 

with  connective  tissue,  but  is  really  nothing  but  a  peculiarly  trans- 
formed epithelium.  KoUiker,  therefore,  in  1852,  held  the  opinion 
which  those  who  believe  with  me  consider  to-day  the  correct  one, 
but  which  years  afterward  he  very  materially  modified,  almost  to 
the  point  of  entire  abandonment.  This  author  was  the  first  to 
announce  that  the  theory  of  exclusiveness  is  not  tenable,  in  the  pro- 
cess of  development,  from  the  three  original  embryonal  layers,  the 
"ectoderm,"  the  "mesoderm,"  and  the  "entoderm,"  or,  using 
Balfour's  terminology,  the  "epiblast,"  the  "mesoblast,"  and  the 
' '  hypoblast  ; ' '  and  yet  he  narrows  his  views  to  an  almost  incredible 
degree,  in  the  chapter  upon  development  of  enamel. 

John  Tomes,  in  his  "Dental  Physiology  and  Surgery"  (London, 
1848  ;  Philadelphia,  1853),  gives  wonderfully  accurate  drawings  of 
what  he  calls  enamel-pulp,  or  columnar  tissue,  now  known  as  amelo- 
blasts.  On  page  102  he  explains  the  development  of  enamel-rods 
or  fibers  in  the  following  words  :  ' '  The  cells  being  formed  in  lines, 
eventually  become  confluent  ;  the  points  of  union  being  sometimes 
transverse,  and  at  other  times  oblique.  At  this  stage  the  earthy 
elements  are  received,  and  the  lines  of  union  between  the  component 
cells  of  the  fibers  become  less  distinct,  and  are  eventually  lost,  leaving 
a  continuous  fiber.  The  nuclei,  from  the  first  very  small,  are  alto- 
_gether  lost  in  the  formation  of  the  fibers,  or  exist  as  very  fine  tubes 
passing  through  the  length  of  each." 

On  page  104.  we  read  :  "To  the  best  of  my  belief  the  transverse 
striae  are  due  to  the  alternate  dilatation  and  contraction  of  the  fibers, 
— each  dilatation  corresponding  to  the  center  of  a  formative  cell,  and 
each  contraction  to  the  junction  of  two  cells. ' ' 

Ifrom  these  quotations  it  becomes  evident  that  John  Tomes  was  a 
most  careful  observer.  Even  at  that  early  date,  with  the  limited 
pow;ers  of  his  microscope,  he  conceived  the  full  truth  when  he  stated 
' '  that  each  enamel-rod  is  the  result  of  a  juxtaposition  of  formative 
cells,  between  which  are  left  the  striae."  He  considers  the  formative 
cells  as  the  recipients  of  the  calcareous  matter  in  exactly  the  same 
way  that  we  see  it  to-day. 

F.  Waldeyer,  in  his  "  Handbook  of  Histology,"  edited  by  Strieker 
(Leipzig,  1869),  page  347,  describes  the  formation  of  enamel  in  the 
following  manner  :  ' '  The  formation  of  enamel  is  done  exclusively  by 
the  enamel-epithelium,  since  the  enamel-prisms  are  the  result  of  a 
direct  calcification  of  its  long  cylindrical  cells.  The  boundary  of 
petrifaction  on  the  cells  is  by  no  means  linear,  but  extends  downward 
to  an  irregular  depth, — a  fact  which  likewise  is  not  in  favor  of  the 
view  that  a  secretion  of  the  enamel-cells  is  being  calcified.  After 
treatment  of  young  enamel  with  dilute  acids,  the  enamel-prisms 
swell  slightly  and  resume  entirely  the  forms  of  the  previous  cylindrical 

3 


l8  DENTAL    PATHOLOGY    AND    PRACTICE. 

cells.  The  disappearance  of  the  nuclei,  in  the  process  of  the  calcifi- 
cation of  the  cells,  is  of  so  common  occurrence  that  their  absence  in 
the  enamel  cannot  cause  any  wonder.  Enamel,  therefore,  is  to  be 
considered  as  the  petrified  dental  epithelium." 

This  author  explains  the  formation  of  the  stellate  reticulum  by  a 
transformation  of  the  epithelia,  and  considers  its  gelatin  of  a  merely 
mechanical  importance,  to  keep  an  open  space  for  the  growing  tooth. 
John  and  Charles  S.  Tomes,  in  their  ' '  System  of  Dental  Surgery' ' 
(London,  1873),  page  253,  say,  "The  conclusions  respecting  the 
development  of  enamel  which  are  most  in  accordance  with  appear- 
ances observed  are  these  :  The  columns  of  the  enamel-organ 
(enamel-cells,  internal  epithelium  of  the  enamel-organ)  are  subserv- 
ient to  the  development  of  the  enamel-prisms  into  which  they  by 
calcification  become  actually  converted.  This  conversion  goes  on 
in  the  following  method  :  The  proximal  end  of  the  cell  undergoes 
some  chemical  change  preparatory  to  calcification,  and  is  subse- 
quently calcified  ;  but  this  calcification  does  not  go  on  uniformly 
throughout  its  whole  thickness,  but  proceeds  from  its  periphery 
toward  its  interior,  the  central  portion  of  the  cell  thus  being  calcified 
later  than  the  external  portion,  which  lies  at  the  same  level.  At  the 
same  time  that  calcification  is  proceeding  inward,  in  each  individual 
cell,  it  has  united  the  contiguous  cells  to  each  other.  The  calcifica- 
tion of  the  central  portions  of  the  enamel-fibers  does  not  keep  pace 
with  that  of  their  exteriors,  nor  even  in  fully  completed  enamel  does 
it  attain  to  precisely  the  same  characters.  In  the  progress  of  calcifi- 
cation the  nuclei  of  the  enamel-cells  disappear,  and  it  is  probable,  as 
is  believed  by  Waldeyer,  that  the  internal  epithelium  of  the  enamel  is 
reunited  by  the  cells  of  the  stratum  intermedium  as  it  becomes  itself 
used  up  by  advancing  calcification,  converting  it  into  enamel-fibers." 

These  authors  give  credit  to  Kolliker  as  the  originator  of  the  idea 
that  the  enamel-cells  do  not  undergo  direct  conversion  into  enamel- 
fibers,  but  that  the  enamel  is,  as  it  were,  shot  out  from  their  ends  ; 
that  is,  it  is  a  secretion  from  them,  not  a  deposition  of  lime-salts  into 
their  own  substance.  Our  quotations  from  Kolliker' s  original  Ger- 
man work,  issued  in  Leipzig  in  1852,  plainly  show  that  at  that  time 
he  believed  fully  in  the  conversion  theory.  Since  the  Tomeses  quote 
from  the  fifth  German  edition  of  Kolliker's  Histology,  issued  in  1867, 
it  is  obvious  that  he  had  changed  his  views,  much,  in  my  judgment, 
to  his  own  disadvantage. 

The  views  taken  in  a  series  of  papers  upon  the  history  of  develop- 
ment of  the  enamel  by  C.  Heitzmann  and  C.  F.  W.  Bodecker, — 
"  Contributions  to  the  History  of  Development  of  the  Teeth"  {Inde- 
pendent Practitio7ier,  vols,  viii,  ix,  1887-S8), — are  in  harmony  with 
my  own  observations,  and  furnish  the  foundation  for  what  I  have  to 


GROWTH    OF   ENAMEL. 


19 


add,  in  the  way  of  a  more  comprehensive  explanation  of  the  process 
of  building  enamel,  than  has  heretofore  been  advanced.  This  I  pro- 
pose to  give  in  as  few  words  as  I  conveniently  can  and  make  myself 
clearly  understood. 

Fig.  8. 


BE 


Tooth  of  Human  Fetus,  Six  Months. 

/'.papilla;  ZJi,  non-calcified  dentine ;  i?2,  calcified  dentine ;  £•,  enamel ;  /I,  rowof  ameloblasts  ; 
M,  medullary  corpuscles  at  the  peripheral  portion  of  ameloblasts  ;  G,  globular  corpuscles  from 
which  ameloblasts  develop  ;  EE,  buds  of  external  epithelium  ;  F,  follicle,  made  up  of  fibrous 
connective  tissue.     Magnified  100  diameters. 


Fig.   8  gives  an  illustration  of  these  views.     The  figure,   it  must 
be  emphasized,  is  not  diagrammatic,  but  copied  with  the  utmost  care 


20  DENTAL  PATHOLOGY  AND  PRACTICE. 

from  one  of  Bodecker's  specimens  of  a  human  fetus  six  months 
old,  the  period  at  which  enamel  begins  to  appear.  The  different 
layers,  it  will  be  observed,  appear  to  be  separated  from  one  another. 
This  is  usually  the  case  in  even  the  most  carefully  prepared  speci- 
mens, owing  to  slight  mechanical  injury  in  cutting,  and  shrinkage  of 
the  soft  parts  ;  the  relations,  however,  are  absolutely  correct  in  this 
drawing. 

After  the  epithelial  peg  has  grown  into  the  depth  of  connective 
tissue  of  the  oral  mucosa,  in  the  twelfth  week  of  embryonal  devel- 
opment, the  distal  end  of  this  peg  becomes  club-shaped,  and  then 
appears  the  first  trace  of  medullary  tissue,  which  two  weeks  later 
plainly  shows  the  stellate  reticulum.  The  club  at  this  period  assumes 
a  cup  shape,  whose  concave  surface  is  lined  by  the  internal  epithe- 
lium, while  the  outer  surface  is  made  up  of  the  so-called  external 
epithelium,  which  is  in  uninterrupted  continuity  with  the  internal 
epithelium  at  the  most  prominent  border  of  the  cup.  If  we  examine 
the  lower  edge  of  the  cup  of  the  enamel-organ  at  about  the  six- 
teenth week  of  embryonal  life,  we  observe  a  peculiar  change  in  the 
columnar  bodies  of  the  internal  epithelium,  which  consists  in  the 
appearance  of  highly  glistening  globular  bodies,  in  a  more  or  less 
row-like  arrangement,  replacing  the  previous  columnar  epithelia. 
These  bodies  are  either  solid  or  slightly  vacuoled,  and  are  forma- 
tions of  living  matter  such  as  we  are  accustomed  to  look  upon  as 
medullary,  embryonal,  or  indifferent  corpuscles  in  their  earliest 
stage  of  appearance.  Obviously  these  glistening  globules  have 
originated  from  the  reticulum  of  living  matter  of  the  columnar 
epithelia  themselves.  This  conclusion  is  justified  from  the  fact  that 
we  can  trace,  step  by  step,  the  growth  of  these  glistening  granules 
up  to  the  formation  of  the  glistening  lumps  which  we  have  termed 
medullary  corpuscles.  The  more  the  cup  of  the  enamel-organ  is 
enlarged,  the  more  conspicuous  becomes  the  transmutation  of  the 
previous  internal  epithelium  into  glistening  lumps  ;  so  much  so  that 
toward  the  end  of  the  fifth  month  of  fetal  life  the  original  columnar 
epithelium  at  the  concave  portion  of  the  cup  has  entirely  disappeared. 
In  its  stead,  other  bodies  closely  resembling  columnar  epithelia,  now 
known  as  ameloblasts,  or  enamel-formers,  begin  to  show,  first  at  the 
deeper  portion  of  the  cup. 

From  this  description  it  seems  evident  that  all  previous  observers 
— with  due  respect  to  their  judgment — have  been  in  error  in  the 
assumption  that  the  columnar  epithelia  of  the  internal  wall  of  the 
cup  were  identical  with  the  ameloblasts.  All  of  them  have  over- 
looked the  intermediate  stage  of  the  glistening  medullary  lumps. 
In  Fig.  8  these  lumps  are  marked  G.  They  are  traceable  down  to 
the  neck  of  the  papilla,  therefore  to  the  point  of  recurvation  of  the 


GROWTH    OF    ENAMEL.  21 

previous  internal  into  the  previous  external  epithelium.  The  lumps, 
I  wish  to  repeat,  are  extremely  glossy,  with  a  high  degree  of  refrac- 
tion. They  are  arranged,  at  first  irregularly,  in  a  layer  of  consider- 
able breadth,  higher  up  in  rows,  and  by  their  coalescence  and  pro- 
longation give  rise  to  small  columns,  the  ameloblasts.  These  are 
seen  up  to  the  end  of  the  fifth  month  of  fetal  development  at  the 
deepest  concavity  of  the  cup  and  its  lateral  walls  down  to  varying 
depths,  and  closely  attached  to  the  now  forming  dentinal  cap.  The 
odontoblasts  grow  smaller  toward  the  thin  extremity  of  the  dentinal 
cap,  and  below  its  end  they  appear  as  blunt  and  short  columns, 
while,  close  above,  the  ameloblasts  make  their  appearance,  being 
traceable  all  around  the  outer  periphery  of  the  dentinal  cap. 

In  the  sixth  month  of  fetal  life,  as  is  well  known,  the  enamel-cap 
begins  to  show  ;  first  at  the  summit  of  the  dentinal  cap,  where  it 
gains  its  greatest  breadth,  gradually  becoming  thinner  toward  the 
sloping  sides,  and,  as  a  whole,  a  trifle  thinner  and  shorter  than  the 
dentinal  cap. 

If  we  now  examine  the  ameloblasts  close  above  the  already-formed 
enamel,  we  will  observe  finely  granular  bodies,  arranged  in  a  row, 
between  the  enamel  and  ameloblasts.  These  are  best  seen  in  speci- 
mens where  the  hardening  and  cutting  procedures  have  not  caused  a 
detachment  of  the  soft  tissues  from  the  hard, — i.e.,  the  enamel-organ 
from  the  calcified  enamel.  It  is  seldom  that  this  is  accomplished  ; 
but  a  few  of  such  perfect  specimens  are  in  Bodecker's  collection, 
which  by  his  kind  permission  I  have  used  for  my  studies  and  these 
drawings.  Even  though  a  slight  detachment  has  occurred,  the 
enamel-organ  still  remains  intact,  and  the  finely  granular  corpuscles  at 
the  proximal  ends  of  the  ameloblasts  remain  visible. 

What  are  these  finely  granular  bodies  ?  The  last-named  authors 
claim  that  they  are  medullary  corpuscles,  holding  small  and  indis- 
tinct or  no  nuclei,  and  only  a  very  small  amount  of  living  matter, 
which  accounts  for  their  finely  granular  appearance  with  low  powers 
of  the  microscope.  They  further  claim  that  these  corpuscles,  or  the 
liquids  contained  in  their  reticulum,  become  solidified  into  basis-sub- 
stance, and  immediately  infiltrated  with  lime-salts.  They  claim  also 
that  the  enamel-rods  are  built  up  by  rows  of  such  calcified  or 
"petrified"  medullary  corpuscles,  the  successive  arrangement  of 
which  into  rows  causes  the  more  or  less  regular  appearance  of  the 
transverse  striae  of  Retzius,  whereas  between  the  rows  longitudinal 
interstices  will  remain,  filled,  perhaps,  with  a  small  amount  of  cement- 
substance,  differing  in  its  chemical  constitution  from  the  basis-sub- 
stance of  the  rods  proper,  and  in  its  interior  holding  extremely 
delicate  fibrillae  (Bodecker's  enamel-fibers),  which  branch  into  the 
transverse  striae.     Being:  satisfied  that  the  views  of  these  gentlemen 


22 


DENTAL    PATHOLOGY    AND    PRACTICE. 


are  correct,  I  will  simply  add  a  new  feature,  to  make  those  views 
more  symmetrical, — and,  as  it  occurs  to  me,  it  is  a  feature  of  consid- 
erable importance  :  viz,  the  changes  that  take  place  in  the  amelo- 
blasts  during  the  process  of  the  formation  of  enamel.      (Fig.  9,) 

Fig.  9. 


First-Formed  Enamel  of  Human  Fetus,  Six  Months. 

D,  dentine;  E,  enamel  toward  the  dentine,  made  up  of  irregular  calcified  fields,  toward  the 
periphery  of  prisms  with  transverse  interruptions  ;  M,  medullary  corpuscles  finely  granular, 
from  which  the  enamel-prisms  are  formed  ;  A,  ameloblasts,  toward  the  enamel  breaking  up  into 
medullary  corpuscles,  toward  the  periphery  rebuilt  by  such  corpuscles ;  ^i,  irregular  amelo- 
blasts torn  from  their  connection  with  enamel:  F,  fibrous  connective  tissue,  changing  to 
medullary  tissue.     Magnified  800  diameters. 


The  ameloblasts,  as  just  stated,  split  up  into  rows  of  finely  granu- 
lar medullary  corpuscles,  and  consequently  are  reduced  considerably 
in  their  size.  In  fact,  it  is  difficult  to  find  full-sized  ameloblasts  at 
the  summit  of  the  enamel-cap,  where  the  production  of  enamel  is 
most  active,  the  same  as  it  is  impossible  to  find  full-sized  odonto- 
blasts at  the  summit  of  the  papilla,  where  the  formation  of  dentine 


GROWTH    OF    ENAMEL.  23 

is  most  active.  The  mutilated  ameloblasts  in  this  situation  still 
exhibit  nuclei,  although  their  forms  are  odd, — mostly  cut  or  broken, 
with  offshoots  running  upward  and  laterally  toward  the  stratum 
intermedium.  At  the  same  time  peculiar  glistening,  homogeneous 
lumps  and  irregular  wedge-shaped  nucleated  bodies  appear  between 
the  offshoots  of  the  ameloblasts  ;  not  as  regular,  however,  as  the 
original  medullary  corpuscles  were,  from  which  the  ameloblasts 
originally  developed.  All  these  indifferent  bodies  must  have  arisen 
from  the  living  material  stored  up  in  the  stratum  intermedium,  close 
above  the  row  of  ameloblasts.  By  their  occasional  row-like  arrange- 
ment I  am  led  to  the  conclusion  that  they  serve  for  a  restitution  or 
rebtiilding  of  the  ameloblasts  (which  at  their  proximal  ends  have  split 
up  into  enamel-formers),  and  thus  serve  to  establish  a  continuity  of 
the  ameloblasts,  and,  in  turn,  of  the  enamel-rods,  throughout  the 
entire  thickness  of  the  enamel.  In  Chapter  II  I  have  endeavored 
to  show  that  odontoblasts,  being  split  up  at  their  distal  ends  into 
medullary  corpuscles,  enter  directly  into  the  formation  of  the  basis- 
substance  of  dentine,  at  the  same  time  being  superadded  to  at  their 
proximal  ends  by  medullary  corpuscles  derived  from  the  living  matter 
of  the  papilla.  Thus  the  continuity  of  the  odontoblasts  and  dentine 
is  established,  stratification  of  the  dentine  being  the  exception.  I 
now  assert  a  similar  procedure  for  the  ameloblasts,  in  a  reverse  direc- 
tion, owing  to  the  centrifugal  direction  of  enamel  growth.  The  amelo- 
blasts being  broken  up  at  their  proximal  ends  into  medullary  corpuscles^ 
which  are  directly  transformed  into  btocks  of  enam.el-rods ,  are  super- 
added to  at  their  distal  or  peripheral  ends  by  medullary  corpuscles 
derived fro7n  the  stratum  ifitermedium.  Normal  enamel  is  non-strati- 
fied ;  its  rods  or  prisms  run  a  wavy  course,  as  a  rule  uninterruptedly, 
from  near  the  dentine  to  the  cuticular  (Nasmyth's)  membrane. 

In  Chapter  VI  stratified  enamel  is  described  as  rather  an  anom- 
alous occurrence,  it  being  as  a  rule  connected  with  pigmentation  of  its 
rods.  The  study  of  this  condition  enabled  me  to  show  the  manner 
in  which  enamel  is  formed, — first  in  crown  layers  around  and  upon 
the  cusps,  and  much  later  in  lateral  or  neck  layers  at  the  sides  of  the 
crowns.  This  fact  again  proves  that  the  most  active  formation  of 
enamel  always  takes  place  at  the  summit  of  the  crowns  or  upon  the 
cusps  ;  while  the  lateral  layers  are  formations  of  a  much  later  date, 
and  are  much  thinner. 

Neither  the  structure  nor  the  development  of  this  tissue  is  to  me 
explicable  on  the  basis  of  the  cell  theory,  which  suggests  that  each 
cell  is  an  individual,  and  only  exceptionally  in  connection  with  its 
neighbor.  To  me  a  cell  is  a  lump  of  protoplasm,  in  which  the  living 
matter  is  stored  up  in  different  shapes.  The  glistening  globules  of 
small  size,  having  arisen  from  the  protoplasm  of  the  original  columnar 


24 


DENTAL    PATHOLOGY    AND    PRACTICE. 


epithelia  of  the  enamel-organ,  represent  a  juvenile  condition  of  living 
matter  in  its  most  compact  aggregation. 

The  medullary  corpuscles,  sprung  from  the  ameloblasts,  show  only 
a  delicate  reticulum  of  living  matter,  being  ready  for  immediate  trans- 
formation into  basis-substance  and  for  calcification.  Between  these 
extreme  stages  stand  the  ameloblasts,  with  their  vesicular  nuclei,  and 
a  markedly  heavy  reticulum  of  living  matter  in  their  interior.  The 
indifferent  corpuscles,  serving  to  supply  additions  to  the  ameloblasts, 
exhibit  all  the  intermediate  stages  between  small,  globular,  glossy, 
and  compact  globules  up  to  distinctly  nucleated  protoplasmic  lumps. 
Whatever  the  size  and  shape  of  such  lumps  may  be,  they  are  invari- 
ably connected  with  one  another  by  means  of  delicate  offshoots,  which 

Fig.  io. 


Ameloblasts  beginning  the  Formation  of  Enamel  ;  from  Human  Fetus,  Six  Months. 
D,  border  of  newly-formed  dentine  ;  E,  first  trace  of  forming  enamel ;  A,  row  of  ameloblasts  ; 
Jl/i,  medullary  corpuscles  for  restitution  of  ameloblasts  ;  M",  medullary  corpuscles  just  previous 
to  their  infiltration  with  lime- salts  ;  F,  fibrous  connective  tissue,  the  so-Called  intermediate  layer. 
Magnified  looo  diameters. 

vary  greatly  in  thickness  and  in^their  course.  Each  ameloblast  sends 
offshoots  toward  the  dentine  in  great  numbers,  known  as  Tomes  pro- 
cesses. They  also  run  upward  toward  the  intermediate  layer,  and 
laterally  for  the  immediate  union  of  neighboring  ameloblasts.  (See 
Fig.  ID.) 

Broad  and  clumsy  offshoots,  such  as  are  depicted  by  Tomes  and 
Waldeyer,  are  seen  only  upon  torn  and  teased  ameloblasts.  So  long 
as  these  bodies  are  in  situ  the  offshoots  are  always  delicate,  and  visible 
with  higher  powers  of  the  microscope  only, — i.e.,  from  800  to  1000  di- 
ameters. Through  the  splitting  up  of  the  ameloblasts  in  a  longitudinal 
direction,   delicate  wedge-shaped  pieces  are   seen    to  arise  between 


GROWTH    OF    ENAMEL. 


25 


funnel-shaped  or  square  bodies.  By  the  coalescence  of  the  lateral 
offshoots  in  a  longitudinal  direction,  delicate  fibrillae  originate  between 
the  ameloblasts,  known  as  Bodecker's  enamel-fibers. 

While  the  formation  of  a  tissue  is  going  on,  it  seems  probable, 
from  the  great  variety  of  forms  of  the  protoplasmic  bodies,  that  there 
is  not  for  a  moment  rest  either  in  the  growth  or  in  the  new  formation 
of  living  matter.  Thus  the  proximal  ends  of  the  ameloblasts  are 
metamorphosed,  through  the  intermediate  stage  of  medullary  cor- 
puscles, into  the  calcified  basis-substance  of  the  enamel-rods.  The 
distal  ends  exhibit  the  stages  through  which  the  living  matter  passed 
before   the   original   ameloblasts   were   formed.      Still   the   question 

Fig.  II. 


Ameloblasts  at  Rest;  from  Developing  Tooth  of  Human  Fetus,  Six  Months. 
^,  row  of  ameloblasts;    /,  /,  intermediate  layer;    M,  myxomatous  reticulum;    P,  papilla; 
S,  so-called  structureless  membrane.     Magnified  1000  diameters. 

remains  an  open  one,  whether  or  not  ameloblasts  are  an  absolute 
necessity  for  the  production  of  enamel  after  the  formation  of  the  rods 
has  once  begun.  The  rows  of  globular  bodies  as  seen  in  Fig.  lo,  M"", 
strongly  favor  a  negative  answer  to  this  query.  Nothing  but  a  trans- 
mutation of  solid  globular  lumps  of  living  matter  into  delicately  retic- 
ulated medullary  corpuscles  seems  to  be  required  for  the  building  up 
of  the  minute  blocks  of  enamel-rods,  without  the  intermediate  stage 
of  ameloblasts.  We  must  admit,  however,  that,  for  symmetry  of 
construction,  the  part  played  by  these  bodies  seems  essential. 
Although  varying  greatly  in  size,  even  in  the  same  tooth,  ameloblasts 
are  to  be  considered  as  merely  provisional  formations,  and  by  no 
means  stable  or  unchangeable.  This  conclusion  is  the  same  as  that 
we  reached  in  regard  to  the  significance  of  odontoblasts. 


26  DENTAL    PATHOLOGY   AND    PRACTICE. 

Full  development  of  ameloblasts  into  oblong  or  conical  bodies, 
each  containing  one  or  two  nuclei,  sharply  bordered  by  a  delicate 
cuticular  formation  toward  the  papilla,  and  distinctly  marked  by 
the  intermediate  layer  toward  the  enamel-organ,  is  seen  only  in 
the  condition  of  temporary  rest,  where  the  formation  of  enamel 
has  not  as  yet  started.  (See  Fig.  ii.)  As  soon  as  the  first  trace 
of  enamel  is  seen  the  ameloblasts  lose  their  regularity  by  being  split 
up  toward  the  dentine,  and  are  superadded  to  from  the  intermediate 
layer. 

The  first  enamel  to  appear  is  made  up  of  irregular  angular  and 
glistening  lumps,  varying  greatly  in  size.  (See  Figs,  g  and  lo.)  The 
first  blocks  of  enamel-rods  show  compact  edges  and  comparatively 
thin  and  translucent  centers,  in  which  traces  of  the  nuclei  of  the 
medullary  corpuscles  even  are  to  be  seen.  This  shows  plainly 
the  correctness  of  the  assertion  of  Tomes,  that  "the  enamel-rods  are 
calcified  from  the  periphery  toward  the  center."  The  irregularity 
toward  the  first-formed  calcified  blocks  also  accounts  for  the  fact  that 
fissures  and  breaks  are  of  such  common  occurrence  in  specimens  of 
enamel,  either  ground  or  cut,  at  the  border  toward  the  dentine,  as 
demonstrated  in  the  chapter  on  the  anomalies  of  enamel,  such 
anomalies  being  most  common  in  this  situation. 

We  now  return  to  the  enamel-organ,  of  which  it  is  known  that  it 
begins  to  show  at  the  end  of  the  third  month  of  intra-uterine  life, 
by  the  appearance  of  medullary  corpuscles  between  the  internal  and 
external  epithelium.  From  the  fourth  month  to  the  seventh  or 
eighth,  the  beautiful  stellate  reticulum  known  as  the  enamel-organ 
comes  to  view.  ,  Although  Huxley  and  Kolliker  stated  in  1850-52 
that  this  is  connective  tissue,  all  the  later  writers,  including  Kolliker 
himself,  insist  that  it  is  a  peculiarly  modified  epithelium.  I  contend 
that  this  reticulum  is  true  myxomatous  tissue,  and  the  stratum  inter- 
medium true  fibrous  connective  tissue.  The  first  microscopist  to 
describe  and  illustrate  the  intermediate  layer  was  John  Tomes,  in 
1848,  in  his  work  before  quoted,  though  the  credit  for  this  is  usually 
given  to  Hannover,  whose  work  appeared  in  1856. 

As  to  the  significance  of  the  enamel-organ,  I  must  take  decided 
exception  to  the  views  of  most  modern  writers,  viz,  that  it  serves  as 
a  kind  of  protecting  cushion,  or  to  preserve  an  open  space  for  the 
tooth  to  grow  into.  In  my  opinion  the  view  first  announced  by 
Hertz  in  1866,  that  "the  enamel-organ  is  stored-up  material  for  the 
benefit  of  the  growing  enamel  itself,"  the  same  as  is  the  intermediate 
layer,  is  the  correct  idea.  The  reasons  for  this  are  given  by  Heitz- 
mann  and  Bodecker  in  their  paper  quoted  above. 

One  fact  will  strike  every  observer,  viz,  that  the  enamel  is  seldom, 
if  ever,  perfectly  symmetrical  in  the  growing  tooth,   one  side   being 


GROWTH    OF   ENAMEL. 


27 


broader,  to  the  extent  of  five  or  six  times,  than  the  other  ;  some- 
times it  is  found  only  on  one  side  of  the  developing  tooth,  while  on 
the  other  nothing  but  delicate  fibrous  connective  tissue  is  seen.  From 
these  facts  we  must  conclude  that  the  myxomatous  form  of  this  organ 
is  by  no  means  a  characteristic  or  an  absolute  necessity. 

How  are  we  to  explain  the  scantiness  of  this  organ  at  the  summit 
of  the  crown,  where  the  enamel  at  its  full  development  has  the  great- 
est thickness  ?    Can  the  original  enamel-organ,  even  if  ever  so  broad, 

Fig.  12. 


Developing  Tooth  of  Sheep's  Fetus,  10  Centimeters  Long. 

D,  dentine  in  longitudinal  and  transverse  sections;  A,  row  of  ameloblasts  at  rest;  A^, 
ameloblasts  broken  up  into  medullary  tissue,  preceding  the  formation  of  enamel ;  /,  /,  inter- 
mediate layer;  il/,  71/,  myxomatous  enamel-organ  ;  C,  capillary  blood-vessels.  Magnified  1000 
diameters. 

suffice  for  the  production  of  all  the  enamel  ?  Is  not  the  enamel  coat 
of  a  temporary  tooth  five,  nay,  ten  times  as  broad,  as  the  original 
enamel-organ  ?  All  this  points  strongly  toward  the  fact  that  the 
budding  external  epithelium,  and  even  the  primary  epithehal  peg, 
must  furnish  material  for  the  building  of  enamel,  no  matter  what  the 
intermediate  or  subsequent  changes  of  this  tissue  may  be. 

I  have  studied  the  development  of  enamel  in  pigs  and  sheep,  and 
have  found  the  relations  similar  to  those  in  human  beings.  (See  Fig. 
12.)     In  the  sheep's  fetus,  ten  centimeters  long,  the  form-changes 


28  DENTAL    PATHOLOGY   AND    PRACTICE. 

of  the  ameloblasts  are  especially  pronounced,  since  shortly  before  the 
appearance  of  the  enamel  a  splitting  into  medullary  corpuscles  takes 
place  for  the  production  of  enamel-rods,  and  at  the  same  time  new 
medullary  corpuscles  show  themselves  at  their  distal  ends,  evidently 
produced  at  the  expense  of  the  intermediate  layer. 


CHAPTER   IV. 

TEETH    OF   THE    LOWER  JAW   AT   BIRTH. » 

The  object  aimed  at  in  this  chapter  is  to  show  that  the  temporary 
teeth,  so  far  as  their  crowns  are  concerned,  are  in  aij  advanced  stage 
of  development  at  the  time  of  birth,  and  consequently  not  subject 
to  the  imperfections  caused  by  any  of  the  diseases  of  childhood. 
This  accounts  for  the  generally  perfect  or  nearly  perfect  condition  in 
which  we  usually  find  them  ;  while  the  crowns  of  the  permanent  set, 
being  less  advanced  in  their  development,  that  is,  being  perfected 
after  birth,  are  in  consequence  subject  to  the  effects  of  all  local  dis- 
turbances of  the  mucous  membrane. 

It  will  be  remembered  that  Heitzmann  and  Bodecker,  in  their 
' '  Contributions  to  the  History  of  the  Development  of  Teeth, ' '  brought 
their  researches  up  to  the  ninth  month  of  fetal  life.  I  have  extended 
their  studies  up  to  the  time  of  birth,  in  order  to  ascertain  at  this 
period  the  progress  of  development  of  the  temporary,  as  well  as  of 
the  permanent  teeth,  during  the  last  month  of  fetal  life.  The  re- 
sults are  here  presented. 

Two  lower  jaws  of  apparently  well-developed  new-born  babes  were 
excised  soon  after  death,  stripped  of  their  soft  tissues,  and  placed  for 
preservation  in  alcohol.  Afterward  they  were  placed  in  a  half  of 
one  per  cent,  solution  of  chromic  acid,  for  the  purpose  of  decalcifying 
the  hard  tissues,  while  preserving  the  soft  structures.  I  call  attention 
especially  to  this  method  since  it  has  proven,  in  my  hands,  to  be  the 
safest  for  the  preservation  of  the  teeth.  Previous  descriptions  of  de- 
veloping teeth  have  been  questioned  in  Germany  on  the  ground  that 
the  preservation  of  the  tissues  was  not  thoroughly  provided  for.  After 
repeated  renewals  of  the  chromic  acid  solution,  the  jaws  were  sup- 
posed to  have  become  soft  enough  to  be  cut  with  a  razor  ;  but  it  was 
found  that  the  central  portions,  after  they  had  been  cut  up  into  blocks, 
were  still  hard,  and  had  to  be  again  immersed  in  the  chromic  acid 
solution,  for  the  completion  of  the  decalcification.  The  blocks  had 
been  obtained  from  the  right  half  of  each  of  the  jaws,  and  were  cut 
radially  in  order  to  secure  antero-posterior  vertical  sections.     The 

*  Abbott.     Proceedings  of  the  World's  Columbian  Dental  Congress,  1893. 


TEETH    OF    THE    LOWER  JAW   AT    BIRTH.  29 

blocks  were  imbedded  in  celloidin,  sliced  into  thin  sections,  and  each 
section  numbered  with  the  utmost  care,  in  order  to  keep  the  succession 
of  the  teeth  unbroken.  Thus  the  sections  could  be  examined  and 
those  selected  for  mounting  which  contained  teeth  or  exhibited  fea- 
tures belonging  to  the  process  of  the  development  of  teeth.  The 
sum  total  of  the  sections  thus  obtained  was  one  hundred  and  twenty- 
five.  Out  of  these,  again,  only  those  were  selected  for  study  and 
drawing  which  showed  the  teeth  in  greatest  perfection,  the  most  cen- 
tral sections  being  selected  for  drawing. 

Before  entering  into  a  description  of  the  teeth,  I  wish  to  say  that 
one  of  the  jaw-bones,  under  the  microscope,  was  found  to  be  slightly 
rachitic,  as  was  proven  by  some  scanty  islands  of  hyaline  cartilage 
found  in  the  bone-tissue,  though  the  baby  was  to  all  appearances 
normal.  Previous  observations  have  established  the  fact  that  con- 
genital rachitis  is  first  shown  under  the  microscope  by  a  retardation 
of  development  of  bone-tissue  in  the  lower  jaw,  before  any  abnor- 
mal symptoms  appear  to  the  naked  eye  either  on  the  skull  or  shaft 
bones.  It  is  evident  that  in  this  case  the  rachitic  process  has  caused 
a  slight  delay  in  the  formation  of  dentine  and  enamel.  This  asser- 
tion is  clearly  established  by  a  comparison  with  the  sections  ob- 
tained from  the  second  jaw,  in  which  there  was  not  the  slightest 
symptom  of  rachitis.  The  best  specimens,  however,  and  most  of 
the  drawings,  were  obtained  from  the  first  jaw,  the  slight  deficiency 
in  the  deposition  of  lime-salts  enabling  me  to  obtain  nearly  perfect 
sections,  whereas  nearly  all  of  the  sections  of  the  second  jaw  were 
torn  and  very  imperfect. 

Another  difficulty  arose.  As  before  stated,  all  the  sections  were 
made  in  an  antero-posterior  vertical  direction.  Some  of  the  tempo- 
rary, and  most  of  the  permanent  front  teeth,  are,  as  is  well  known, 
irregular  or  devious  while  within  the  jaw,  so  much  so  that  the  direc- 
tion of  the  sections  does  not  always  fully  comply  with  the  expression; 
consequently  some  of  the  drawings  may  not  correspond  to  the  great- 
est height  or  designed  diameter  of  the  tooth  illustrated. 

The  first  tooth  met  with  was,  of  course,  the  central  incisor.  (See 
Fig.  13.)  The  papilla  of  this  tooth  exhibited  a  bluntly  ovoid  shape, 
with  a  somewhat  broader  top,  and  tapering  slightly  to  the  lower  end. 
As  a  matter  of  course,  the  entire  papilla,  at  this  stage,  is  destined 
for  the  production  of  the  crown  of  the  tooth  only,  no  trace  of  the 
future  root  yet  being  present. 

The  papilla  is  composed  ^of  a  myxo- fibrous  connective  tissue, 
throughout  its  main  bulk,  and  is  scantily  supplied  with  capillary  blood- 
vessels. The  periphery  of  the  papilla  shows  a  row  of  odontoblasts 
at  the  labial  aspect  only,  and  even  here  not  complete,  since  the  lowest 
third  of  the  papilla  lacks  in  this  respect.      Here,  and  on  one-half  of 


30  DENTAL  PATHOLOGY  AND  PRACTICE. 

the  summit,  as  well  as  along  the  entire  lingual  aspect,  the  surface  of 
the  papilla  exhibits  a  myxomatous  medullary  tissue,  without  any  ad- 
mixture of  delicate  bundles  of  fibrous  connective  tissue,  with  which 
the  remainder  of  the  papilla  is  abundantly  supplied.  The  summit  of 
the  papilla  is  covered  with  a  dentine  and  enamel  cap,  the  former 
slightly  exceeding  the  latter  in  diameter.  The  dentine-cap  is  farther 
advanced  in  development  on  the  labial  than  on  the  lingual  aspect  ; 

Fig.  13. 


Central  Temporary  Incisor. 

E,  enamel-cap  ;  /?,  dentine-cap  ;  IE,  inner  epiihelium,  ameloblasts  ;  M,  medullary  layer,  from 
which  enamel  forms;  EO,  enamel-organ;  OE,  outer  epithelium  broken  up;  P,  papilla;  O, 
TOW  of  odontoblasts  ;  R,  recurvation  of  inner  into  outer  epithelium.     Magnified  50  diameters. 


it  exhibits  a  non-calcified  portion  nearest  the  papilla,  which  has 
assumed  a  deep  stain  from  the  carmine  ;  the  calcified  portion  remain- 
ing unstained. 

The  border  line  between  the  two  is  marked  by  the  well-known 
globular  deposit  of  lime-salts.  The  enamel-cap,  of  a  greenish-brown 
color  (due  to  the  chromic  acid),  stops  short  of  the  dentine-cap,  and 
is,  at  its  peripheral  portion,  made  up  of  regularly  developed  prisms. 


TEETH    OF   THE    LOWER   JAW  AT    BIRTH. 


31 


The  inner  epithelium,  from  which  the  ameloblasts  arise,  produces  a 
perfect  row  all  around  the  papilla,  with  the  exception  of  the  apex. 
The  place  of  recurvation  to  the  outer  epithelium,  which  latter  is  con- 
siderably broken  up  at  this  stage  of  development,  is  noticeably  deeper 
on  the  labial  than  on  the  lingual  aspect.  The  space  between  the 
inner  epithelium  and  the  already  formed  tooth  is  produced  by  a 
detachment  of  the  former  from  the  latter,  showing  plainly  a  layer  of 

Fig.  14. 


Permanent  Central  Incisor. 
E,    enamel-cap ;    D,   dentine-cap ;    IE,   inner  epithelium ;   EO,   enamel-organ ;    OE,   outer 
epitlielium  ;    P,  papilla  ;  R,  recurvation  of  inner  into  outer  epithelium  ;    O,  medullary  tissue 
forming  odontoblasts.    Magnified  50  diameters. 


protoplasmic  bodies,  into  which  the  ameloblasts  have  retrogressed 
before  becoming  infiltrated  with  lime-salts.  Since  this  feature  is  pro- 
nounced in  all  the  teeth  of  the  jaws  under  consideration,  the  specimens 
are  of  great  value  in  assisting,  at  least,  in  settling  the  still  mooted  ques- 
tion as  to  the  mode  of  development  of  enamel.  I  propose  to  dwell 
more  fully  upon  this  topic,  after  the  description  of  the  cuspid  tooth. 
The  permanent  central  incisor  (see  Fig.  14)  is  a  formation  with  a 


32 


DENTAL  PATHOLOGY  AND  PRACTICE. 


considerably  broader  papilla,  but  with  a  less  developed  enamel  and 

dentine  cap,  than  the  corresponding  temporary  tooth.     The  papilla 

is  made  up  exclusively  of  medullary  tissue,  supplied  scantily  with 

blood-vessels,  none  of  which  could  be  seen  in  the  specimen  from  which 

the  illustration  was  taken. 

Fig.  15. 


Temporary  Lateral  Incisor. 
E,  enamel-cap ;  D,  dentine-cap ;    IE,   inner  epithelium;  ameloblasts ;   M,  medullary  layer, 
from  which  enamel  forms  ;  EO,  enamel-organ  ;   OE,  outer  epithelium  broken  up  ;  P,  papilla  ; 
C,  O,  rows  of  odontoblasts  ;  R,  recurvation  of  inner  into  outer  epithelium.    Magnified  50  diam- 
eters. 

Both  the  inner  and  the  outer  epithelium  were  plainly  visible.  The 
enamel-organ  is  much  less  advanced  in  the  formation  of  myxomatous 
tissue,  especially  at  the  point  of  recurvation  of  the  epithelia,  than  in 
the  temporary  tooth. 

The  temporary  lateral   incisor  (see  Fig.    15)  has  a  papilla  much 


TEETH    OF    THE    LOWER   JAW  AT    BIRTH.  33 

longer  than  that  of  the  central  ;  at  the  same  time  it  is  of  a  more 
cylindrical  form,  but  otherwise  of  identical  structure  in  all  respects. 
On  the  top  of  the  papilla  we  notice  a  rounding  labial  aspect,  and  a 
sharply  pronounced  angle  at  the  lingual  portion.  We  observe  a  row 
of  odontoblasts  only  at  the  central  portion  of  the  labial  surface,  at 
the  summit,  and  along  the  upper  two-thirds  of  the  lingual  aspect, 
while  the  remainder  of  the  surface  is  occupied  by  a  medullary  tissue, 
destitute  of  fibrous  elements,  the  same  as  in  the  central  incisor. 
The  dentine-cap  is  considerably  broader  than  that  of  the  central  in- 
cisor, and  extends  farther  down  upon  the  labial  surface.  It  of  course 
forms  a  decided  angle  at  the  lingual  portion  of  the  top  of  the  tooth. 
The  border  line  between  the  non-calcified  and  calcified  portions  of 
the  dentine  is  more  conspicuous  in  this  tooth  through  the  presence 
of  globular  deposits  of  lime-salts,  than  in  the  central  incisor.  The 
enamel  is  of  about  the  breadth  of  that  of  the  central,  and  follows  strictly 
in  its  general  contour,  the  dentine-cap.  A  pronounced  feature  in 
this  tooth  is  the  medullary  tissue  occupying  the  space  between  the 
row  of  ameloblasts  and  the  surface  of  the  tooth.  The  myxomatous 
enamel-organ  in  both  temporary  incisors  does  not  show  a  well-de- 
veloped reticulum,  but  in  its  stead  is  a  finely-granular  protoplasmic 
mass,  obviously  a  stage  of  development  in  the  progressive  formation 
of  the  myxomatous  reticulum. 

The  permanent  lateral  incisor  (see  Fig.  i6)  has  an  oblong  papilla, 
notable  for  the  abrupt  stopping  of  the  enamel  and  dentine  caps  at 
the  lingual  aspect,  and  also  for  the  precipitous  lingual  portion  of  its 
upper  one-half  The  blood-vessels  traversing  the  medullary  tissue 
of  the  papilla  are  comparatively  few  in  number.  A  fully-developed 
row  of  odontoblasts  is  to  be  seen  only  at  the  lingual  and  posterior 
cutting-edge,  the  remainder  of  the  cutting-edge  being  mostly  desti- 
tute of  these  bodies.  The  other  portions  of  the  papillary  surface 
show  only  rows  of  medullary  corpuscles  tending  toward  the  formation 
of  odontoblasts.  A  conspicuous  feature  in  this  specimen  is  the  dif- 
ference between  the  points  of  recurvation  of  the  epithelia,  embracing 
at  the  labial  aspect  quite  a  portion  of  the  bottom  of  the  papilla  ; 
while  at  the  lingual,  it  barely  reaches  down  one-half  its  length. 

The  temporary  cuspid  (see  Fig.  17)  has  a  papilla  which,  it  will  be 
observed,  is  somewhat  triangular  in  shape,  with  a  sharply-pointed 
apex,  apd  irregularly  rounded  at  the  base  ;  with  the  lingual  portion 
extending  down  slightly  beyond  the  labial.  The  structure  of  the 
papilla  does  not  materially  differ  from  that  of  the  incisors,  the  number 
of  capillaries  also  being  about  the  same.  A  row  of  odontoblasts  is 
observable,  but  only  at  the  lower  portions  of  the  surface  of  the  tooth 
on  the  labial  and  lingual  aspects.  The  summit  is  occupied  by  a  well- 
pronounced  myxomatous  tissue,  the  remainder  of  the  surface  by  a 

4 


34 


DENTAL    PATHOLOGY    AND    PRACTICE. 


medullary  formation.  The  dentine-cap  is  very  broad,  and  sharply 
pointed  at  its  summit.  It  extends  far  down  along  the  surfaces  of  the 
papilla,  more  so  anteriorly  than  posteriorly.  The  non-calcified  por- 
tion is  decidedly  narrower,  and  the  globular  boundary  line  less  pro- 
nounced, than  in  the  incisors.  The  enamel-cap  is  likewise  very 
broad,  stopping  short  of  the  dentine-cap,  and  is  regularly  developed 
in  every  respect. 

Fig.  i6. 


Permanent  Lateral  Incisor. 
E,  enamel-cap;  D,  dentine-cap;  IE,  inner  epithelium;  EO,  enamel-organ;  R,  recurvation 
of  inner  into  outer  epithelium  ;   O,  rows  of  odontoblasts  ;  /*,  papilla.    Magnified  50  diameters. 

The  sections  obtained  from  the  cuspid  were  so  perfect  that  they 
could  be  and  were  advantageously  utilized  to  assist  in  settling  certain 
mooted  questions  as  to  the  development  of  dentine  and  enamel.  In 
the  first  place,  the  odontoblasts,  since  their  discovery,  have  been 
considered  by  the  majority  of  histologists  as  the  dentine-formers 
proper. 


TEETH    OF    THE    LOWER   JAW  AT    BIRTH. 


35 


It  was  Heitzmann  and  Bodecker,  in  their  above-quoted  paper,  who 
first  denied  the  direct  transformation  of  the  odontoblasts  into  den- 
tine, but  claimed  that  they  are  first  broken  up  into  medullary  cor- 
puscles at  the  distal  ends,  which  become  infiltrated,  first,  with  a  glue- 
yielding  basis-substance,  and  afterward  with  lime-salts,  and  that  the 
offshoots  of  the  original   odontoblasts,  being  the  dentinal    fibrillae, 

Fig.   ty. 


Temporary  Cuspid. 
.£,  enamel-cap  ;  Z),  dentine-cap  ;  /I/,  myxomatous  tissue  ;  P,  papilla  ;   O,  row  of  odontoblasts. 
Magnified  50  diameters. 


pass  between  the  calcified  medullary  corpuscles  in  their  respective 
canaliculi.  Every  odontoblast  sends  off"  one  or  more  fibrillae.  This 
fact  has  apparently  made  it  impossible  for  s'ome  observers  to  clearly 
understand  the  formation  of  the  basis-substance.  So  great,  indeed, 
has  been  the  difficulty  that  some  observers  have  resorted  to  the 
supposition  of  specific  fiber-cells  for  the  production  of  these  fibrillae,. 


36 


DENTAL  PATHOLOGY  AND  PRACTICE. 


the  odontoblasts   proper,   according  to   their  view,   producing  only 
the  basis-substance. 

This  view  was  met  at  the  time  it  was  announced  by  a  demonstra- 
tion showing  that  the  "fiber-cells"  were  wedge-shaped  odontoblasts, 
most  numerous  where  the  odontoblasts  are  arranged  around  a  sharp 

Fig.  i8. 


ieofi/^lRD  e-o  ■  rw_ 


Summit  of  Papilla  of  Temporary  Cuspid. 
C,  calcified  dentine;    N,  non-calcified  dentine,  with  globular  deposits  of  lime-salts  at  the 
border  between  calcified  and  non-calcified  dentine ;  /^.flattened  out  indifferent  or  medullary 
tissue;  jl/,  myxomatous  tissue;  /*,  myxo-fibrous  tissue  of  papilla  with  capillary  blood-vessels. 
Magnified  800  diameters. 

curve,  especially  at  the  summit  of  the  papilla.  In  the  pig's  fetus, 
for  instance,  the  summit  of  the  papilla  is  occupied  almost  exclu- 
sively by  these  narrow  and  wedge-shaped  odontoblasts.  The  diffi- 
culty is,  however,  easily  overcome  by  the  demonstration  of  the 
presence  of  medullary  corpuscles  at  the  periphery  of  the  papilla, 
directly  beneath  the  already -formed  dentine.     In  my  specimens,  espe- 


TEETH    OF   THE    LOWER   JAW  AT    BIRTH. 


37 


cially  the  cuspid,  one  is  struck  by  the  scantiness  of  the  rows  of 
odontoblasts  and  the  presence  of  medullary  elements  in  their  stead, 
one  row  of  odontoblasts  being  visible  on  a  portion  of  the  labial, 
another  on  a  portion  of  the  lingual  surfaces  only.  Not  infrequently 
the  odontoblasts  are  arranged  at  acute  angles  to  the  dentinal  canal- 
iculi.     (See  Fig.  17.)    This  feature  may  possibly  be  attributable  to  the 


0.    I.       A.       M. 


Lateral  Portion  of  Temporary  Cuspid. 
O,  enamel-ors:an  ;  /.intermediate  layer;   A,  row  of  ameloblasts  ;   M,  medullary  tissue;  E, 
enamel;   C,  calcified  dentine  ;   A^,  non-calcified  dentine  ;   /'.papilla.     Magnified  800  diameters. 

hardening  process  and  the  subsequent  disfigurement  by  shrinkage, 
although  good  reasons  may  be  adduced  to  the  contrary,  as  the  speci- 
mens are  so  perfect  in  all  other  respects.  The  greater  part  of  the 
area  of  the  surface  of  the  papilla  is  occupied  by  a  medullary  tissue, 
which  is  claimed  to  be  the  dentine-builder  proper.  In  our  cuspid, 
the  summit  is  occupied   by  a  myxomatous  tissue,   approaching  in 


38  DENTAL  PATHOLOGY  AND  PRACTICE. 

gracefulness  almost  that  of  the  enamel-organ.  (See  Fig.  1 8. )  Between 
this  myxomatous  tissue  and  the  border  of  the  non-calcified  dentine 
clusters  of  indifferent  or  medullary  corpuscles  are  seen,  arranged 
longitudinally  along  the  surface  of  the  papilla,  therefore  not  as  yet 
adapted  for  the  formation  of  dentine.  Beneath  the  myxomatous 
tissue  we  find  vascularized  myxo-fibrous  tissue,  constituting  the  main 
bulk  of  the  papilla. 

Professor  Ebner,  of  Vienna,  in  the  "  German  Hand-Book  of  Den- 
tistry," 1 89 1,  by  J.  Schefif,  Jr.,  claims  that  the  characterization  of 
medullary  corpuscles  as  the  dentine-formers  shows  the  interpretation 
of  poorly-preserved  specimens.  In  view  of  this  assertion,  I  will 
draw  the  gentleman's  attention  to  these  illustrations,  taken  from  per- 
fect specimens,  and  ask  him  how  he  accounts  for  the  absence  of 
odontoblasts  where  they  should  be  and  the  presence  of  medullary 
tissue  in  their  stead.  Obviously,  there  is  a  series  of  tissue-changes 
preceding  the  appearance  of  dentine,  and  one  of  the  links  in  the 
chain  is  the  odontoblast. 

At  the  lateral  portion  of  the  cuspid,  evidence  is  to  be  found  by 
which  the  question  of  the  formation  of  enamel  may  possibly  be  set- 
tled. (See  Fig.  19.)  Between  the  fully-developed  enamel  and  the  row 
of  ameloblasts  at  that  point  there  is  a  broad  layer  of  medullary 
tissue,  considerably  broader,  indeed,  than  in  any  other  specimen  of 
developing  human  teeth  I  have  ever  before  seen.  Ebner  takes  issue 
with  the  view  ' '  that  the  ameloblasts  are  not  direct  enamel-formers ,  but 
only  transient  formations  ^  origi?iating  from  a  coalescerice  of  medullary 
co7'puscles  and  breaking  up  again  into  such  corpuscles  before  the 
appearance  of  enamel-tissued  Can  he  or  any  one  else  explain,  may 
I  ask,  the  composition  of  enamel-prisms,  of  square  or  many-sided 
blocklets  (the  forms  admitted  by  all  observers),  except  by  the  con- 
struction of  each  enamel-rod,  by  a  succession  of  medullary  cor- 
puscles becoming  infiltrated  with  lime-salts  ? 

It  is  unnecessary  for  me  to  state  here  that  I  seriously  object  to  the 
assertion  of  Ebner  or  any  one  else  that  the  specimens  from  which  the 
conclusions  he  combats  were  or  are  imperfect.  The  greatest  care 
having  been  taken  in  their  preparation,  I  can  vouch  for  their  per- 
fection. With  equal  propriety,  I  might  ask  the  learned  professor 
why  it  is  that  his  specimens  were  so  imperfect  as  to  not  show  the 
fibers  between  the  enamel- prisms,  or  the  medullary  tissue  between 
the  ameloblasts  proper  and  the  formed  enamel. 

The  permanent  cuspid  (see  Fig.  20)  has  a  papilla  considerably 
broader  than  that  of  the  temporary,  so  much  so  that  it  could  be  illus- 
trated entirely  only  with  a  power  of  twenty-five  diameters.  The 
labial  aspect  is  far  more  bulky  than  the  lingual  ;  the  former  being 
precipitous,    the   latter   more   gently  tapering.      It   is   composed  ot 


TEETH    OF   THE    LOWER   JAW  AT    BIRTH. 


39 


medullary  tissue,  without  the  slightest  admixture  of  the  myxo-fibrous 
or  fibrous  connective  variety,  and  is  at  the  same  time  poorly  supplied 
with  blood-vessels.  Both  dentine  and  enamel- caps  are  as  yet  nar- 
row, terminating  upon  the  labial  side  abruptly,  an  apparent  stricture 
presenting  at  their  termination,  beyond  which  the  papilla  bulges  con- 
siderably, while  on  the  lingual  side  both  caps  follow  the  unbroken 
line  of  the  papilla. 

The  temporary  first  molar  (see  Fig.  21)  at  this  stage  of  develop- 
ment is  of  considerable  size  and  importance.  It  presents  in  this  sec- 
tion two  cusps,  of  which  the  lingual  is  quite  noticeably  higher  than  the 


Fig.  20. 


Permanent  Cuspid. 
E,  enamel-cap  ;  D,  dentine-cap  ;   C,  row  of  odontoblasts  ;  P,  papilla.     Magnified  25  diameters. 

buccal,  although  the  latter  is  but  little  less  developed  than  the  former. 
The  papilla  is  a  bulky  mass  of  myxo-fibrous  connective  tissues, 
abundantly  supplied  with  capillary  blood-vessels.  Corresponding  to 
the  valley  between  the  two  cusps,  the  papilla  is  narrower,  bulging 
from  this  point  upward  and  outward.  The  summit  of  the  papilla  of 
the  lingual  cusp  is  higher  and  more  pointed  than  that  of  the  buccal. 
The  papilla  exhibits  a  row  of  odontoblasts  only  upon  the  lower  third 
of  the  lingual  aspect  ;  everywhere  else  its  surface  is  made  up  of 
medullary  tissue,  without  a  trace  of  odontoblasts.  The  summit  of 
the  papilla  of  the  lingual  cusp  exhibits  a  zone  of  myxomatous  tissue 


40 


DENTAL   PATHOLOGY  AND    PRACTICE. 


similar  to  that  described  in  the  papilla  of  the  cuspid.  The  dentine- 
cap  forms  a  continuous  investment  around  the  cusps,  being  narrow  in 
the  valley  between  them  and  slanting  toward  the  base  of  the  papilla, 
reaching  farther  downward  upon  the  buccal  than  upon  the  lingual 
side.  It  is  fully  developed,  and  composed  of  a  narrow  non-calcified 
and  a  broad  calcified  layer,  the  border-line  between  the  two  por- 
tions being  more  globular  in  the  buccal  than  in  the  lingual  cusp. 
The  enamel  is  likewise  continuous,  fully  developed,  and  calcified, 
being  a  trifle  broader  at  the  summit  of  the  lingual  than  at  that  of  the 


Fig 


Temporary  First  Molar. 
BC,   buccal    cusps;    LC,  lingual    cusps;    E,  E,   enatnel-cap ;    D,   D,   dentine-cap;    P,  P. 
papilla  ;   O,  row  of  odontoblasts.     Magnified  50  diameters. 

buccal  cusp.     In  the  valley  between  the  cusps  it  appears  somewhat 
broader  than  the  layer  of  dentine. 

The  permanent  first  bicuspid  (see  Fig.  22),  the  product  of  the  bud 
from  the  first  temporary  molar,  at  birth  corresponds  to  a  temporary 
tooth  four  and  a  half  months  old.  It  is  cone-shaped  and  composed 
of  medullary  tissue,  with  only  scanty  capillary  blood-vessels  at  the 
base  of  the  cone.  As  might  be  expected,  there  is  not  even  a  trace  of 
odontoblasts  visible.  The  papilla  is  covered  with  a  layer  of  columnar 
epithelium,  the  so-called  inner  epithelium  of  the  enamel-organ,  not 
as  yet  transformed  into  ameloblasts. 


TEETH    OF   THE    LOWER   JAW  AT    BIRTH. 


41 


The  point  of  recurvature  of  the  inner  into  the  outer  epithelium  is 
deeper  down  upon  the  buccal  than  upon  the  lingual  aspect  of  the 
papilla.  The  outer  epithelium  is  still  recognizable  as  being  com- 
posed of  short  columnar  epithelium,  surrounded  by  fibrous  connec- 
tive tissue.  Between  the  inner  and  the  outer  epithelium  there  is  a 
well-developed  myxomatous  reticulum,  the  enamel-organ.  The  inter- 
mediate  layer  is   present,   though  as  yet  not  pronounced.      In  the 


Fig.  22. 


Permanent  First  Bicuspid. 
6',  summit   of  papilla;  B,  base   of  papilla;   IE,  inner  epithelium;    OE,  outer  epithelium; 
EO,    enamel-organ ;     /,   intermediate   layer ;     C,    cancellous   bone  lined  by  osteoblasts ;     R, 
recurvation  of  inner  into  outer  epithelium.     Magnified  50  diameters. 

specimen  from  which  the  illustration  is  taken,  the  upper  portion  of 
the  enamel-organ  is  torn  and  partly  missing. 

The  temporary  second  molar  in  our  specimen  (see  Fig.  23)  has 
two  well-developed  cusps,  of  which  the  lingual  far  surpasses  the  buc- 
cal in  size.  This  does  not,  as  a  matter  of  course,  show  the  relation 
between  the  two  cusps  with  certainty,  since  it  is  quite  possible  that 
the  lingual  cusp  was  caught  by  the  knife  at  its  center,  and  therefore 


42 


DENTAL  PATHOLOGY  AND  PRACTICE. 


at  its  greatest  height,  while  the  buccal  cusp  may  have  been  taken  in  a 
more  peripheral  portion  and  thus  appear  smaller  than  it  really  is. 
Between  the  two  cusps  there  is  an  elevation,  covered  only  by  den- 
tine, which  likewise  may  represent  a  cusp  cut  near  its  periphery. 
The  papilla  is  plainly  myxo-fibrous  connective  tissue,  and  freely  sup- 
plied with  blood-vessels.  Rows  of  odontoblasts  are  seen  only  at  a 
small  portion  of  its  periphery.  The  height  of  the  papilla  is  three 
times  greater  at  the  lingual  than  at  the  buccal  portion.  A  striking 
feature  is  the  sharp  boundary-line  at  the  lingual  aspect,  between  the 
portion  of  the  papilla  which  is  covered  with  dentine  and  that  without 

Fig   23 


Temporary  Second  Molar. 
BC,  buccal  cusps  ;  LC,  lingual  cusp ;  E,  E,  enamel-cap  ;  D,  D,  dentine-cap  ;  P,  P,  papilla  ; 
O,  O,  row  of  odontoblasts.      Magnified  50  diameters. 

it,  and  the  bulging  out  of  the  latter.  The  dentine-cap  is  present  all 
over  the  upper  surface  of  the  papilla,  somewhat  broader  at  the  sum- 
mit of  the  lingual  cusp  than  on  the  summit  of  the  buccal  one.  It 
is  a  trifle  broader  at  the  height  of  the  central  elevation  than  in  the 
valleys  at  either  side. 

The  difference  between  the  calcified  and  the  non-calcified  portions 
of  the  dentine  is  quite  marked.  There  are  two  enamel-caps,  one  each 
formed  over  the  lingual  and  buccal  cusps  ;  the  former  almost  twice 
the  breadth  of  the  latter. 

The  permanent  second  bicuspid  (see  Fig.  24)  is  still  younger  in  its 


TEETH    OF    THE    LOWER    JAW    AT    BIRTH. 


43 


development ;  it  corresponds  to  a  temporary  tooth  in  the  fourth  month 
of  embryonal  life.  The  papilla  is  a  blunt  cone  divided  into  a  conical 
upper  portion,  surrounded  by  the  inner  epithelium,  and  a  broad  base 
surrounded  by  fibrous  connective  tissue.  It  is  made  up  entirely  of 
medullary  tissue,  and  shows  blood-vessels  at  its  base  in  small  num- 
bers. The  inner  epithelium  is  quite  conspicuous  by  the  columnar 
shape  of  its  constituent  elements.     The  same  elements  also  produce 

Fig.  24. 


Permanent  Second  Bicuspid. 
P,  papilla;  IE,  inner  epithelium;  OE,  outer  epithelium;  R,  recurvation  of  inner  into  outer 
epithelium;  £0,  enamel  organ;  /,  intermediate  layer;   C,  fibrous  connective  tissue.     Magni- 
fied 50  diameters. 


the  row  of  outer  epithelium,  which  appear  shortened  only  at  the 
summit  of  the  enamel-organ.  The  enamel-organ  itself  is  not  as  yet 
fully  developed,  its  points  of  intersection  being  large,  the  meshes,  on 
the  contrary,  narrow.  The  intermediate  layer  is  but  slightly  pro- 
nounced.    In  this  specimen  the  enamel-organ  was  unbroken. 

The  permanent  first  molar  is  an  unusually  well-developed  tooth  in  our 
series.     (See  Fig.  25.)     It  has  two  well-pronounced  cusps,  the  largest 


44 


DENTAL  PATHOLOGY  AND  PRACTICE. 


being  the  lingual.  The  papilla  is  composed  mainly  of  myxomatous 
and  medullary  tissue,  with  an  admixture  of  some  delicate  fibrous  con- 
nective tissue.  Its  vascular  supply  is  as  yet  scanty.  It  shows  deep  in- 
cisions on  both  the  lingual  and  buccal  aspects,  corresponding  to  the 
termination  of  the  dentine-caps,  beneath  which  the  papilla  bulges  quite 
noticeably.  Rows  of  odontoblasts  are  seen  along  the  greater  extent 
of  the  surface  of  the  papilla,  and  especially  upon  the  lingual  aspect, 
which  shows  an  uninterrupted  row  of  these  formations.  A  second 
row  is  seen  in  the  valley  between  the  two  cusps,  where  as  yet  no  den- 
tine has  formed.  There  are  separate  dentine-caps  for  each  cusp,  that 
over  the  lingual  cusp  being  especially  well  developed. 

Fig.  25. 


Permanent  First  Molar. 
E,  enamel-cap  ;  D,  dentine-cap  ;  /,  depression  on  surface  of  papilla  ;  P,  papilla  ;    O,  row  of 
odontoblasts  ;    IE,  inner  epithelium  ;   OE,  outer  epithelium  ;   EO,  enamel-organ  ;  71/,  medul- 
lary tissue.    Magnified  50  diameters. 

The  enamel- caps  are,  as  is  the  rule  in  all  developing  teeth,  shorter 
than  the  dentine-caps  ;  that  of  the  lingual  cusp  being  at  its  summit 
twice  as  thick  as  that  upon  the  buccal.  The  row  of  inner  epithelia  is 
transformed  into  ameloblasts  over  both  cusps,  and  there  is  a  distinct 
layer  of  medullary  tissue  present  between  the  ameloblasts  and  the 
fully-developed  enamel.  The  outer  epithelium  begins  to  break  up  at 
its  upper  portion,  where  the  enamel-organ  forms  a  broad  layer  of 
myxomatous  tissue. 


TEETH    OF    THE    LOWER   JAW  AT    BIRTH.  45 

Huxley,*  as  early  as  1853,  speaking  of  the  development  of  dentine, 
says,  that  "  it  is  not  explicable  by  the  cell  theory."  How  true  this 
statement,  made  so  many  years  ago.  I  do  not,  however,  agree  with 
his  assertion  that  the  pulp-tissue  takes  no  part  in  the  formation  of 
dentine.  Any  one  who  considers  the  so-called  cells  as  stable  and  un- 
changeable formations  will  be  at  a  loss  to  explain  the  formation  of 
any  tissue  of  the  teeth.  The  latest  researches  in  histology  have  proven 
that,  so  far  as  the  morphological  elements  are  concerned,  there  is 
nothing  stable  during  the  advancing  formation  of  the  organism  and 
its  constituent  parts  ;  nor  during  full  development,  at  the  height  of 
life  ;  and  far  less  is  this  the  case  during  its  decline.  Before  a  tissue  is 
fully  formed  there  are  repeated  oscillations  forward  and  backward,  in 
the  appearance  of  the  morphological  elements  ;  the  intervening  stage 
invariably  being  their  reduction  into  the  stage  of  indifferent,  medul- 
lary, or  embryonal  tissue.  It  has  been  proven  that  the  papilla  of  the 
developing  teeth  may  proceed  to  the  formation  of  the  myxomatous, 
nay  myxo-fibrous  connective  tissue.  At  its  periphery  this  tissue, 
sprung  from  medullary  corpuscles,  falls  back  to  medullary  corpuscles, 
which  unite  into  large  branching  protoplasmic  bodies,  resembling 
columnar  epithelia,  the  so-called  odontoblasts.  These  are  by  no 
means  the  dentine-producers  proper  ;  no  more  so  than  the  osteoblasts 
are  the  real  bone-formers.  Each  of  these  formations  is  nothing  but  a 
pre-stage  toward  the  formation  of  dentinal  or  bone  tissue,  as  the  case 
may  be.  Odontoblasts  break  up  once  more  into  medullary  corpus- 
cles, from  which  at  last,  by  their  infiltration  with  basis-substance  and 
the  immediate  deposition  of  lime-salts,  first  non-calcified,  and  at  last 
calcified  dentine  is  produced.  The  zigzag  line  of  development  of 
dentine,  therefore,  is  first  embryonal  or  medullary  tissue  ;  second, 
myxomatous  or  myxo-fibrous  tissue  ;  third,  embryonal  or  medullary 
tissue  ;  fourth,  odontoblasts  ;  fifth,  again  embryonal  or  medullary 
tissue  ;  and  sixth  and  last,  non-calcified  then  calcified  dentine. 

Every  reduction  to  embryonal  tissue  is  followed  by  a  further  step  in 
advance  in  the  development  of  the  organ,  until  at  last  the  most  perfect 
tissue,  such  as  dentine,  will  make  its  appearance.  It  is  a  question  in 
my  mind  whether  the  dentine,  as  we  see  it  at  the  time  of  birth,  is  a 
lasting  formation,  or  the  same  as  we  see  it  in  the  fully-grown  tempo- 
rary or  permanent  tooth.  The  size  of  the  papilla  and  the  dentine- 
cap  are,  at  birth,  far  too  small  in  comparison  with  what  we  see  at  the 
time  of  eruption.  It  is  quite  possible,  therefore,  that  the  first  formed 
dentine- cap  is  not  necessarily  lasting,  but  may  eventually  be  reduced 
once  more  into  medullary  tissue,  before  the  permanent  breadth  of 
dentine  corresponding  to  the  transverse  diameter  of  a  fully-formed 
tooth  is  reached.      Similar  oscillations   must,    of  necessity, — if  this^ 

*  Quarterly  Journal  of  Microscopical  Science,  1853. 


46  DENTAL  PATHOLOGY  AND  PRACTICE. 

change  occurs, — take  place  in  the  production  of  the  pulp,  and  the 
dentine  of  the  roots.  At  the  time  of  birth,  only  the  papilla  of  the 
crown  is  present,  sharply  bordered  downward  by  fibrous  connective 
tissue.  This  latter  tissue  is  reduced  to  its  embryonal  condition  in 
order  to  produce  the  necessary  material  for  the  production  of  the  den- 
tine of  roots.  Further  observation  will  be  required  in  order  to  settle 
the  question  as  to  how  the  dentine  and  cementum  of  the  roots  are 
formed. 

We  meet  with  the  same  puzzles  in  the  history  of  the  development 
of  the  enamel.  At  the  time  of  birth,  the  myxomatous  enamel-organ 
is  far  too  small  to  enable  us  to  understand  the  formation  of  a  broad 
enamel  layer,  such  as  we  see  at  the  time  of  eruption.  Even  the  first 
established  enamel-caps  are  far  too  small  in  comparison  with  the  diam- 
eter of  the  crowns  of  either  temporary  or  permanent  teeth.  Heitzmann 
and  Bbdecker,  in  their  above-quoted  publication,  the  result  of  eight 
years'  hard  labor,  came  to  the  conclusion  that  the  elements  of  the 
original  epithelial  pegs  are  reduced  to  medullary  tissue,  afterward  to 
fibrous  connective  tissue,  next  to  medullary  tissue,  and  eventually  to 
ameloblasts.  Ameloblasts,  according  to  their  notion,  are  not  direct 
enamel-formers,  no  more  so  than  odontoblasts  are  direct  dentine- 
formers.  The  ameloblasts  are  reduced  to  medullary  corpuscles,  which 
after  infiltration  with  the  basis-substance  and  immediate  deposition  of 
lime-salts,  at  last  produce  enamel-prisms. 

From  a  study  of  their  specimens  and  my  own,  I  am  convinced  that 
these  views  are  correct. 

Should  the  first  enamel- cap  which  appears  prove  too  small  for  a 
fully-grown  tooth,  nothing  is  left  to  solve  the  puzzle  of  development 
but  the  assumption  that  even  the  fetal  enamel-cap  is  not  lasting,  and 
must  undergo  reduction,  or  possibly  repeated  reductions  to  medullary 
tissue,  before  the  fully-developed  tooth  is  reached,  such  as  we  see  at 
the  time  of  eruption. 


CHAPTER   V. 

CONGENITAL  DEFECTS  IN  ENAMEL.* 

Every  dental  practitioner  is  more  or  less  familiar  with  the  condi- 
tion of  imperfect  or  defective  enamel  found  upon  the  crowns  of  per- 
manent teeth  (more  especially  the  incisors  and  first  molars),  which 
I  propose  to  consider  under  the  above  heading.  These  imperfections 
usually  concern   the  summit  of  the  crown   or  its  vicinity.     We  see 

*  Abbott.     Dental  Cosmos,  i^<)i. 


CONGENITAL    DEFECTS    IN    ENAMEL. 


47 


upon  an  otherwise  well-developed  crown  an  almost  circular  ridge, 
above  which  the  enamel  appears  of  a  grayish-brown  color,  and  in  the 
shape  of  numerous  pointed,  thorny  projections,  the  masticating  sur- 
face of  molars  appearing  as  if  provided  with  numerous  minute  stalac- 
tites or  stalagmites.     (See  Fig.  26.) 

In  some  cases  there  are  only  a  few  blunt  or  pointed  hillocks  of 
enamel,  between  which  the  dentine  is  entirely  destitute  of  such 
covering.  In  others  the  dentine  is  nearly  covered  with  enamel, 
leaving  rows  of  small  round  or  oblong  holes  through  it  to  the  den- 
tine.    These  defects  appear,    as  before  stated,    only   in  permanent 


Fig.  26. 


CONGENITALLY   IMPERFECT    CrOWN   OF    LoWER    MOLAR. 

S,  shortened  crown  ;  C,  C,  cones  of  enamel ;  D,  dentine  with  no  enamel  covering.    Magnified 
4  diameters. 

teeth,  and  very  seldom  are  any  of  these  except  the  incisors  and  first 
molars  involved.  Whether  or  not  the  complete  absence  of  enamel 
from  the  crowns  of  incisors,  as  is  sometimes  seen,  is  of  the  same 
nature,  and  due  to  the  same  causes,  I  am  not  prepared  to  say, 
although  it  seems  probable. 

Teeth  of  this  description  are  a  source  of  the  greatest  annoyance 
to  the  patient,  since  the  portions  not  covered  with  enamel  are  usually 
most  exquisitely  sensitive,  rendering  mastication  difficult  and  painful. 
Operations  upon  them  are  so  very  distressing,  that  the  dentist  often 


48 


DENTAL    PATHOLOGY  AND    PRACTICE. 


finds  himself  almost  helpless  to  afford  relief  to  his  patient,  except  by 
the  extraction  of  the  teeth. 

In  looking  with  the  naked  eye  at  a  longitudinal  section  through  a 
molar  affected  as  just  described,  we  at  once  recognize  the  deficiencies 
of  enamel,  the  stalactite  or  stalagmite  appearance,  and  the  shortening 
of  the  crown  sometimes  one-eighth  of  an  inch,  caused  by  these  defi- 
ciencies. 

These  blunt  and  pointed  elevations  are  made  up  partly  of  healthy- 
looking  and  partly  of  a  greenish-brown  enamel.  Between  the  eleva- 
tions are  areas  partly  covered  by  an  extremely  thin  layer  of  enamel 

Fig.  27. 


Section  of  Masticating  Surface,  showing  Partial  Covering  of  Enamel. 
E,  well-developed  enamel;  L,  isolated  lumps  of  enamel;  D,  D,  dentine;  /,  /,  interglobular 
spaces.     Magnified  100  diameters. 

and  partly  destitute  of  any.  By  grinding  the  crown  of  such  a  tooth  in 
longitudinal  section,  for  microscopical  examination,  the  masticating 
surface  presents  an  extremely  striking  image.     (See  Fig.  27.) 

A  well- developed,  though  slightly-pigmented,  enamel  is  seen 
gradually  tapering  toward  the  masticating  surface,  showing  marked 
deficiencies  of  the  outermost  layer.  These  deficiencies  consist  of 
conical  depressions  at  the  surface  and  granulations  near  it.  Obvi- 
ously this  condition  was  caused  by  an  incomplete  calcification  of  the 
enamel,  from  the  fact  that  it  has  taken  up  or  absorbed  a  deep  brown 


CONGENITAL    DEFECTS    IN    ENAMEL. 


49 


pigmentation.  The  tapering  layer  of  enamel  stops  abruptly,  leaving 
the  dentine  entirely  uncovered,  as  is  seen  in  several  places  ;  besides, 
there  are  irregular  hillocks  of  an  irregularly  contoured  enamel,  of  a 
deep  brown  color.  These  hillocks  give  to  the  grinding-surface  the 
appearance  of  groups  of  stalactites.  Slabs  exposed  to  the  action  of 
a  half  of  one  per  cent,  solution  of  chloride  of  gold  for  one  hour 
exhibit  a  dark  violet  color  of  the  dentine  in  the  crevices  between  the 

Fig.  28. 


Isolated  Lump  of  Enamel,  vekv  Imperfect. 

Z',  P,  P,  protoplasmic  projections  into  the  enamel  from  the  dentine  ;   C,  transverse  section  of 
enamel-prisms.     Magnified  500  diameters. 

enamel  lumps,  which  means  that  a  portion  of  the  lime-salts  has  been 
dissolved  out,  although  no  destruction  of  the  organic  portion  of  the 
dentine  has  taken  place.  At  the  usual  distance  from  the  interzonal 
layer  are  seen  interglobular  spaces. 

Let  us  magnify  a   lump  of  enamel   in   this   locality  h\-e   hundred 
diameters.      (See  Fig.  28.) 


50 


DENTAL  PATHOLOGY  AND  PRACTICE. 


We  notice  in  this  specimen  narrow  prisms,  markedly  wavy,  and 
interrupted  by  faint  concentric  striations.  The  prisms,  as  usual,  do 
not  reach  the  surface  of  the  enamel,  but  at  a  given  distance  from  it 
they  are  replaced  by  irregular  angular  pieces.  The  outermost  por- 
tion of  the  lump  is  of  a  dark  brown  color.  Penetrating  the  enamel 
at  varying  heights  are  seen  numerous  pear-shaped  prolongations  of 
the  dentinal  canaliculi,  some  extending  nearly  to  the  surface.  These 
spaces  contain  protoplasm,  and  are  stained  a  deep  violet  color  by  the 
chloride  of  gold.     Aside  from  these  irregularities  the  lump  seems  to 

Fig.  29. 


Imperfect  Enamel. 

E,  well-developed  enamel,  transverse  section ;  G,  G,  granular  layer  of  enamel,  with  pear- 
shaped  protoplasmic  enlargements ;  Z>,  dentine,  canaliculi  in  transverse  and  oblique  sections; 
/,  interglobular  spaces.    Magnified  600  diameters. 

be  thoroughly  calcified,  except  in  a  few  spots  upon  the  surface,  which 
have  taken  a  slight  violet  stain.  The  exposed  dentine  is  also  deeply 
stained  the  characteristic  violet  color  in  this  locality,  denoting  insuffi- 
ciency of  lime-salts,  or  an  excess  of  organic  material  over  the  normal 
proportion. 

I  wish  at  this  point  to  call  attention  to  a  paper  prepared  by  Dr. 
John  I.  Hart,  of  New  York,  in  which  he  has  shown  beyond  a  possi- 
ble doubt,  by  means  of  protracted  staining  with  chloride  of  gold,  that 
imm-ediately  beneath  the  enamel,  within  the  dentine,  there  is  a  very 
minute  reticulum  of  living  matter,  considerably  more  than  is  found 


CONGENITAL    DEFECTS    IN    ENAMEL.  51 

in  Other  portions  of  the  dentine.  This  corroborates  what  Dr. 
Bodecker  stated  in  1878,  and  also  explains  more  satisfactorily  the 
clinical  fact  that  at  this  particular  portion  of  a  carious  cavity  in  a 
tooth,  the  sensibility  is  much  more  acute  than  in  other  parts  of  the 
same  tooth. 

In  some'  instances  the  crown  of  the  tooth  may  be  nearly  covered 
with  a  well-developed  or  a  stratified  and  slightly  pigmented  enamel, 
the  other  portions  being  coated  with  a  thin  layer,  highly  pigmented, 
again  denoting  deficiency  in  lime-salts.     (See  Fig.  29.) 

We  present  here  a  transverse  section  of  the  crown  of  a  molar. 
The  thin  and  irregularly  contoured  enamel  exhibits  only  transverse 
sections  of  prisms,  of  a  deep  brown  color.  At  the  interzonal  layer 
numerous  pear-shaped  protoplasmic  spaces  are  seen  penetrating  the 
enamel,  and  in  the  region  nearest  to  the  dentine  the  prisms  appear  as 
if  they  are  granular  or  sieve-like  (perforated  with  numerous  small 
holes),  indicative  of  a  lack  of  proper  calcification. 

Extremely  interesting  and  instructive  anomalies  are  sometimes 
found  in  the  formation  of  this  tissue,  viz  :  two  distinct  varieties  of 
enamel,  one  upon  the  other.  First,  we  have  an  anomalous  portion 
grafted  or  deposited  upon  a  normal  enamel,  and  again  anomalous 
enamel  first  deposited,  with  the  peripheral  portion  fairly  normal. 
(See  Fig.  30.) 

This  represents  a  cusp  of  a  molar,  with  a  conspicuously  defective 
enamel  deposited  upon  a  nearly  normal  one.  The  normal  portion  is 
slightly  pigmented,  slightly  stratified,  and  supplied  with  a  moderate 
number  of  granulations  near  the  interzonal  layer.  The  outer  or 
peripheral  portion  exhibits  a  layer  which  ends  abruptly  on  one  side, 
and  gradually  blends  with  the  normal  enamel  on  the  other.  This 
portion  is  remarkably  defective  in  its  structure.  At  the  boundary- 
line  between  the  two  portions  the  enamel-prisms  are  abruptly  devi- 
ated, their  longitudinal  course  being  suddenly  changed  to  a  trans- 
verse direction.  In  the  latter  portion  a  few  oblique  sections  are  seen 
alternating  with  the  transverse.  The  whole  portion  superadded  to 
the  normal  enamel  is  pierced  by  innumerable  granulations,  which, 
owing  to  their  violet  color,  we  must  conclude  are  protoplasmic  in 
structure  and,  of  course,  deficient  in  lime-salts.  The  granulations 
are  in  some  places  arranged  in  rows,  in  others  scattered  irregularly. 
If  a  large  mass  of  enamel  exhibits  prisms  almost  rectangular  to  their 
original  normal  direction,  it  is  not  an  evidence  of  the  interlacing  of 
such  prisms,  but  of  their  unusually  wavy  courses. 

An  originally  deficient  enamel  upon  which  is  deposited  a  normal 
one  is  represented  in  Fig.  31.  Here  we  observe  numerous  layers 
made  up  of  extremely  narrow,  interrupted  prisms,  upon  which  at  a 
given  line  prisms  of  normal  width  appear,  first  in  transverse,  then  in 


52 


DENTAL  PATHOLOGY  AND  PRACTICE. 


longitudinal  sections.  This  specimen  affords  a  good  opportunity  to 
trace  one  and  the  same  prism  in  longitudinal,  oblique,  and  transverse 
section. 

In  all  the  teeth  I  have  examined  with  imperfect  enamel,  the 
so-called  interglobular  spaces  were  present  in  the  dentine,  indicating 
a  deficient  calcification  of  territories  at  the  period  of  development 

Fig.  30. 


Imperfect,  Grafted  upon  Perfect  Enamel. 
X*,  dentine;  ^,  boundary  zone  (interzonal  layer);  £,  perfect  enamel;  £i,  imperfect  enamel. 
Magnified  100  diameters. 

which  corresponds  with  that  of  the  formation  of  enamel.  In  only 
one  specimen  have  I  seen  a  devious  course  of  the  dentinal  fibers  and 
stratification  of  the  dentine. 

In  one  instance  peculiar  formations  were  seen  in  the  cementum. 
(See  Fig.  32.) 

The  cementum   here   exhibits   distinct  lamellations  and  scattered 


CONGENITAL    DEFECTS    IN    ENAMEL. 


53 


cement-corpuscles,  with  their  longitudinal  diameters  mostly  arranged 
vertically  to  the  direction  of  the  lamellae.  The  cementum  was 
abruptly  interrupted  by  the  pericementum  dipping  downward  to  the 
close  vicinity  of  the  dentine,  in  which  situation  the  prolongations  of 
the  pericementum  were  hardened  by  globular  depositions  of  lime- 
salts,  which  were  conspicuous  by  their  high  degree  of  refraction. 

Fig.  31. 


Perfect,  Grafted  upon  Imperfect  Enamel. 
.£1,  irregular  and   imperfect  layer  of  enamel  ;  E^,  regular  layer  of  enamel ;  D,  dentine ;  /, 
interglobular  spaces.    Magnified  500  diameters. 

This  anomaly — altogether  different  from  the  process  of  absorption 
of  the  roots  of  temporary  teeth,  or  that  of  bone — must  have  originated 
at  the  time  of  the  development  of  the  cementum,  which,  as  is  well 
known,  takes  place  after  the  formation  of  the  dentine.  The  morbid 
process  was  undoubtedly  pericementitis,  which  led  to  a  partial 
destruction  of  the  pericementum.  At  these  points,  consequently, 
no  cementum  was  deposited. 


54 


DENTAL    PATHOLOGY   AND    PRACTICE. 


A  remarkable  feature  in  connection  with  this  specimen  was  the 
apparently  perfect  condition,  in  the  mouth,  of  the  gum  and  alveolus. 
The  microscope  revealed  nothing  anomalous  in  the  pericementum 
except  a  few  scattered  calcified  patches.  It  is  hardly  possible  that 
there  was  any  special  connection  between  this  condition  and  the 
morbid  process  in  the  enamel,  as  the  enamel  is  completely  formed  at 
a  much  earlier  period  than  this  could  have  occurred. 

Fig.  32. 


Irregularities  of  Cementum.. 
P,    pericementum;    C,   stratified    cementum   with    cement-corpuscles;    E,  excavations    of 
cementum  filled  with  pericementum;  C,  globular  stratified  depositions  of  lime-salts ;  D,D, 
dentine.    Magnified  100  diameters. 


As  to  the  causes  which  lead  to  imperfections  in  the  enamel  and 
other  portions  of  the  teeth  during  the  process  of  development,  A. 
Jacobi,  M.D.,  says  in  an  article  on  "  Dentition  and  its  Derangements," 
1862,— 

"  The  enamel  of  the  teeth  is  subject  to  several  anomalies.  It  may 
be  either  defective  or  discolored.  Its  defective  formation  appears 
either  in  excavations  dispersed  over  the  surface  of  the  tooth,  or  there 
are  complete  furrows  or  transverse  notches  around  the  crown  of  the 
tooth,  the  body  being  still  covered  with  or  entirely  deprived  of 
enamel.  This  atrophy  is  the  result  of  those  severe  diseases  which 
the  child  may  have  been  suffering  from  during  the  development  of 
the  enamel.  Acute  exanthems  are  said  to  produce  the  dispersed 
excavations  ;  acute  inflammatory  diseases,  the  furrows  ;  and  rachitis 


CONGENITAL    DEFECTS    IN    ENAMEL.  55 

has  often  been  observed  to  be  the  cause  of  the  entire  absence  of  the 
enamel.  The  incisors  of  rachitic  children  are  usually  small,  appear 
late,  and  are  very  liable  to  become  carious.  Acute  exanthems  are 
counted  among  the  causes  of  this  anomaly,  especially  by  such 
writers  as  classify  the  teeth  with  the  dermal  tissue.  Smallpox  is 
related  to  produce  isolated  excavations  which  have  a  great  similarity 
to  the  cicatrices  remaining  after  smallpox.  To  vaccination,  also, 
some  have  attributed  the  defective  development  of  the  enamel. 
The  mucous  membrane  of  the  mouth  is  very  irritable, 
being  accustomed  only  to  amniotic  liquor  in  fetal  life,  and  to  milk  in 
the  early  stage  of  extra-uterine  existence.  Every  change  in  the  diet, 
therefore,  the  bad  quality  of  the  material,  or  artificial  nipples,  the 
use  of  candy,  sucking  bags,  or  alcoholic  beverages,  coffee,  or  stimu- 
lants of  whatever  kind,  will  act  as  irritants,  producing  hyperemia  or 
inflammation  in  a  more  or  less  severe  form.  ...  A  more  severe 
form  is  that  known  by  the  name  of  aphthous  stomatitis.  The  super- 
ficial layers  of  the  epithelium  are  not  thrown  off"  during  the  hyper- 
emic  swelling  of  the  mucous  membrane,  as  in  erythematous  stoma- 
titis,, but  a  real  and  visible  change  takes  place  in  the  anatomical 
structure  of  the  follicles.  There  is  a  circumscribed,  punctated,  vas- 
cular injection  around  a  follicle  which  is  gradually  infiltrated  by  exu- 
dation. The  consecutive  swelling  increases  in  proportion,  the  folli- 
cles will  burst  and  exhibit  a  superficial  erosion  or  ulceration,  and  the 
adjacent  mucous  membrane  will  be  sympathetically  affected." 

In  "  Contributions  to  the  Development  of  the  Teeth"  (Heitzmann 
and  Bodecker,  hidependent  Practitioner,  vols,  viii-ix)  will  be  found 
several  descriptions  of  anomalies  of  deciduous  teeth  depending  upon 
congenital  rachitis. 

In  "Studies  of  Pathology  of  Enamel  of  Human  Teeth,  with 
Special  Reference  to  the  Etiology  of  Caries"  (see  Chapter  VI),  refer- 
ence is  made  to  pigmentation,  stratification,  and  white  spots  in  the 
enamel,  all  of  which  are  attributed  to  imperfect  calcification.  Con- 
genital disturbances  of  the  epidermis  are  known  to  influence  the  devel- 
opment of  teeth  to  no  small  extent. 

Edmund  Lesser  says,  "In  the  majority  of  haired  men,  which 
means  congenital  growth  of  hair  all  over  the  face  (hirsuties),  I  have 
hitherto  observed  that  defects  or  irregularities  of  the  dental  system 
were  present,  since  not  only  a  number  of  teeth,  but  the  corresponding 
alveoli,  were  missing.  In  some  cases  with  normal  dentures  a  broad- 
ening of  the  alveolar  processes  was  apparent. 

We  know  that  the  enamel  originates  from  the  epithelium  of  the 
oral  cavity  of  the  embryo.  At  the  development  of  two  months  of 
the  fetus  we  can  trace  an  epithelial  peg  which  leads  to  and  is  in  con- 
nection with  the  epithelium  of  the  oral  cavity.     This  peg  is  prolonged 


56  DENTAL    PATHOLOGY  AND    PRACTICE. 

inwardly,  and  in  the  third  month  of  development  becomes  club- 
shaped  at  its  deepest  extremity.  It  is  well  known  that  this  epithelial 
peg,  more  especially  its  club-shaped  portion,  serves  for  the  formation 
of  the  enamel-organ.  At  about  the  third  month,  lateral  epithelial 
offshoots  begin  to  appear  from  the  main  peg.  The  former  furnishes 
the  material  for  the  production  of  the  enamel  of  the  temporary  tooth, 
while  the  lateral  pegs  furnish  the  enamel-organs  of  the  permanent 
teeth. 

Although  of  epithelial  origin,  the  enamel-organ  is  of  a  myxomatous 
structure,  and  thus  represents  a  variety  of  connective  tissue.  The 
history  of  development  of  enamel  (which  makes  its  appearance  about 
the  seventh  month  of  fetal  life)  is  well  understood,  as  far  as  tempo- 
rary teeth  are  concerned,  up  to  the  time  of  birth  of  the  child.  Still 
we  know  nothing  as  to  the  progress  of  the  lateral  pegs  in  laying  the 
foundation  of  the  enamel-organ  and  the  enamel  of  the  permanent 
teeth.  We  simply  conclude  that  the  process  is  identical  with  that  of 
the  temporary  teeth,  in  its  development  during  the  earliest  years  of 
extra-uterine  life.  Since  the  imperfections  of  enamel,  as  described, 
are  observed  upon  permanent  teeth  only,  I  venture  the  hypothesis, 
without  fear  of  contradiction,  that  diseases  of  the  oral  cavity  only 
affecting  the  epithelial  layers,  and  the  pegs  derived  therefrom,  must 
cause  these  defects.  Such  diseases  occur  in  the  oral  cavity  of  young 
children,  under  the  headings  of  inflammation  (stomatitis),  from  many 
causes,  leading  to  the  formation  of  blisters,  ulcers,  and  abscesses. 
Growth  of  mildew  (so-called  thrush)  is  known  to  be  a  fertile  source 
of  both  such  superficial  and  deep-seated  disturbances. 

Acute  exanthems,  which  sometimes  spread  to  the  mucous  mem- 
brane of  the  oral  cavity,  undoubtedly  play  an  important  part  in 
causing  inflammation  of  the  enamel-organ,  which  results  in  produc- 
ing defective  enamel. 

We  can  appreciate  the  probability  that  inflammation  will  partially 
destroy  either  the  original  epithelia  or  the  enamel-organ  derived 
therefrom,  and  thus  be  the  direct  cause  of  defective  enamel.  The 
simple  obliteration  of  a  number  of  blood-vessels  which  surround 
this  organ  would  suffice  to  so  interfere  with  its  proper  function  as 
to  diminish  the  amount  of  lime-salts  deposited  ;  the  enamel-prisms 
in  such  case  might  develop  normally  as  to  size,  but  show  deficiency  in 
calcification.  If,  with  the  inflammation  and  obliteration  of  blood-ves- 
sels, hemorrhage  takes  place  into  the  enamel-organ,  or  infusion  of 
hemoglobin  should  occur,  pigmentation  of  the  deficiently  calcified 
prisms  would  become  intelligible. 

We  can  realize  that  the  medullary  tissue  giving  rise  to  enamel- 
prisms  will,  in  consequence  of  inflammation,  be  so  altered  or  mis- 
placed that  the  outcome  would  be  imperfect,  incomplete,  or  devious 


PATHOLOGY    OF   THE    ENAMEL.  57 

prisms.  As  shown  in  Chapter  VI,  the  formation  of  enamel  takes  place 
in  the  shape  of  layers  for  the  crown  and  layers  for  the  neck.  We  may 
thus  grasp  the  possibility  that  the  earliest  crown  layers  may  be  fully 
and  regularly  developed,  while  the  last  crown  layers  are  interfered 
with  and  become  defective.  Should,  therefore,  an  inflammatory  pro- 
cess start  at  the  time  of  the  appearance  of  the  earliest  crown  layers, 
and  soon  abate,  the  enamel  nearest  to  the  dentine  will  be  found  imper- 
fect. If  the  inflammatory  disturbance  continues  for  a  long  period, 
the  result  will  be  a  thin  and  incompletely  calcified  layer  of  enamel. 
Should  portions  of  the  enamel-organ  be  completely  destroyed  by 
suppuration,  entire  absence  of  enamel  at  such  points  will  be  the 
result.  A  number  of  so-called  miliary  abscesses  in  the  enamel- 
organ  will  lead  to  a  porous  or  ' '  pitted' '  enamel.  A  limited  number 
of  somewhat  larger  abscesses  would  cause  larger  holes  or  pits,  or 
possibly  the  entire  enamel-organ  might  be  destroyed,  so  that  the 
dentine  would  be  entirely  unprotected. 

In  all  the  cases  of  teeth  with  defective  enamel  that  I  have  exam- 
ined, the  dentine  has  been  found  fully  developed  and  perfectly  calci- 
fied, with  the  exception  of  quite  numerous  interglobular  spaces. 
These  appear  in  the  dentine  at  the  period  of  development  during 
which  the  enamel-organ  was  affected,  indicating  very  positively  that 
the  disease  or  diseases  which  caused  the  production  of  imperfect 
enamel  was  local  rather  than  general,  as  has  been  supposed  by  some 
pathologists. 


CHAPTER    VI, 


STUDIES    OF    THE     PATHOLOGY    OF    ENAMEL    OF    HUMAN    TEETH, 
WITH  SPECIAL  REFERENCE  TO  THE  ETIOLOGY  OF  CARIES.® 

Recognizing  the  fact  that  pathological  conditions  of  the  dental 
organs  frequently  result  from  congenital  defects  in  the  structure  of 
the  enamel,  more  especially  of  the  permanent  teeth,  I  purpose  to  con- 
sider in  this  chapter  the  importance  of  these  imperfections  as  factors 
in  the  predisposing  causes  of  the  early  destruction  of  the  teeth  by 
the  carious  process. 

One  of  the  most  important  questions  in  dentistry  has  always  been 
the  pathology  and  etiology  of  caries.  Thoughtful  dentists  have 
long  agreed  that  there  is  a  marked  difference,  not  only  among  indi- 
viduals, but  also  in  races,  in  the  liability  of  teeth  to  decay.  Not  many 
years  since  a  prominent  dentist  of  New  York  directly  accused  civil- 

*  Abbott,  Denial  Cosmos,  1885. 


58  DENTAL  PATHOLOGY  AND  PRACTICE. 

ization  of  being  the  most  conspicuous  factor  in  its  production.  It 
is  an  undeniable  fact  that,  with  advancing  refinement  of  individuals 
and  nations,  decay  of  teeth  is  more  prevalent.  It  seems  to  me,  how- 
ever, that  even  this  recognized  fact  will  not  altogether  explain  the 
rapidly  growing  tendency  to  this  disease  under  all  circumstances.  It 
has  many  times  occurred  to  me  that  there  must  be  an  anatomical 
deficiency  to  fully  explain  the  liability  to  caries  in  each  single  in- 
dividual, aside  from  the  acquired  local  causes  to  which  caries  has 
usually  been  attributed  heretofore.  Unquestionably,  there  are  auxil- 
iary agents  in  producing  or  forwarding  decay  of  teeth,  such  as  certain 
kinds  of  food,  more  especially  sweets,  which  are  too  often  retained 
in  the  fissures  always  found  in  the  grinding-surfaces  of  certain  teeth, 
between  the  teeth,  upon  irregular  teeth,  uneven  surfaces  of  the  enamel, 
etc.  But  all  these  cannot  fully  explain  the  fact  that  the  simple  change 
in  modes  of  living  should  manifest  itself  in  the  sudden  and  rapid  de- 
struction of  these  organs.  Strong,  healthy  individuals,  upon  being 
transferred  from  a  country  with  comparatively  simple  habits  of  life  into 
a  country  of  high  refinement,  may  soon  become  victims  of  caries  of 
their  teeth.  Modern  Germans  and  Irish,  immigrating  to  America 
and  enjoying  luxuries  (similar  to  those  enjoyed  by  comparatively 
civilized  old  Egyptians,  in  whose  mummies  we  observe,  not  without 
some  surprise,  a  pronounced  tendency  toward  decay  of  the  teeth), 
soon  discover,  to  their  great  discomfort,  at  least,  that  their  teeth  are 
becoming  diseased. 

With  these  questions  in  mind,  I  undertook  to  examine  a  large 
number  of  teeth  which  had  been  ground  into  thin  slabs,  with  the 
precaution  of  preserving  their  soft  parts,  especially  their  living  mat- 
ter, a  method  first  introduced  into  microscopic  technique  by  Dr.  C. 
F.  W.  Bbdecker.  The  results  of  my  observations,  though  not  ex- 
haustive, are  highly  satisfactory,  inasmuch  as  they  explain,  quite 
positively,  the  tendency  of  certain  teeth  to  decay,  the  cause  of  which 
is  in  direct  relation  to  and  dependent  upon  imperfections  in  their 
anatomical  structure.  Upon  these  observations,  I  claim  that  certain 
deficiencies  in  the  minute  structure  of  the  enamel  must  be  certainly 
considered  as  playing  a  most  important  part  in  the  etiology  of  caries. 

Before  entering  upon  a  description  of  the  anomalies  of  enamel 
which  I  have  observed,  I  wish  to  briefly  recapitulate  the  description  of 
the  structure  of  this  tissue,  and  its  relation  to  dentine,  as  first  dis- 
covered and  published  by  Bodecker,  in  his  essay  entitled  "  The  Dis- 
tribution of  Living  Matter  in  Human  Dentine,  Cement,  and  Enamel. ' ' 
(^Dental  Cosmos,  1878-1879.)  According  to  this  observer,  the  enamel 
is  composed  of  rods  and  fibers  having  a  slightly  wavy  course,  inter- 
laced between  delicate  interstices.  In  these  interstices  run  delicate 
fibers    of  living   matter,    sending  into  the  enamel-rods  minute  off- 


PATHOLOGY    OF   THE    ENAMEL.  59 

shoots  in  a  prevailingly  vertical  direction,  thus  producing  the  cross- 
lines  which  have  long  been  known  to  exist  in  the  enamel-rods,  but 
which  were  shown  by  him  to  be  far  more  delicate  and  more  numerous 
than  had  ever  before  been  described.  The  square  pieces  of  the  enamel- 
rods  are  again  subdivided  into  minute  fields  ;  they  are  separated 
from  one  another  by  delicate  light  interstices,  and  in  all  probability 
contain  fibrillae  of  living  matter.  The  enamel  is  thus  raised  to  the 
dignity  of  a  living  tissue  instead  of  a  mere  calcareous  deposit,  as  under 
the  old  conception.  At  the  place  of  junction  of  the  enamel  with  the 
dentine  a  direct  connection  is  often  seen  between  the  enamel  and  den- 
tine fibers.  More  commonly  dentinal  fibers  run  into  the  enamel  varying 
distances,  without  a  direct  union  between  them  and  the  enamel-fibers  ; 
as  the  latter  do  not  generally  reach  the  surface  of  the  dentine,  but 
terminate,  at  different  heights,  above  its  level,  while  the  zone  close 
above  their  terminations  is  occupied  by  a  delicate  irregular  net-work. 
In  many  places  the  dentinal  canaliculi,  upon  entering  the  enamel, 
suddenly  become  enlarged  and  form  spindle  or  pear-shaped  cavities 
of  varying  diameters.  They  invariably  contain  protoplasm  which  is 
in  direct  connection  with  the  terminations  of  the  dentinal  fibers,  and 
on  their  periphery  with  the  fibers  of  living  matter  of  the  enamel.  In 
the  teeth  of  young  persons  the  spindle-shaped  enlargements  are 
comparatively  larger  and  more  regular  than  in  the  teeth  of  old  people. 
The  boundary  line  between  the  dentine  and  enamel  is  usually  slightly 
wavy  and  with  more  or  less  deep,  bay-like  excavations,  the  concavi- 
ties of  which  are  directed  toward  the  dentine. 

I. — Anomalous  Relation  between  Dentine  and  Enamel. 

In  examining  a  large  number  of  specimens  of  ground  teeth,  I  met 
with  formations  in  two  instances  which  are  to  be  considered  as 
anomalous,  although  not  strictly  pathological.  In  one  case,  that  of 
a  temporary  molar,  there  was  on  the  buccal  surface  a  protrusion  of 
dentine  into  the  enamel  with  a  fluted  surface,  which  was  produced 
by  a  series  of  bay-like  excavations,  which  were  present  also  at  the 
junction  of  the  dentine  with  the  enamel  in  this  tooth  in  general,  but 
not  so  marked  as  in  this  protruding  spot.  (See  Fig.  33.)  The 
center  of  this  protrusion  was  occupied  by  an  eccentric  protoplasmic 
formation,  differing  in  shape  from  the  ordinary  interglobular  spaces. 
The  dentinal  fibers  at  the  periphery  were  bifurcated  in  the  usual  man- 
ner, but  very  few  of  them  penetrated  the  enamel.  The  portion  ol 
the  enamel  nearest  to  the  protrusion  was  destitute  of  prisms,  while  in 
the  immediate  vicinity  such  prisms  were  traceable  almost  in  contact 
with  the  dentine.  The  zone  immediately  above  the  protrusion  was 
but  slightly  brownish,  whereas  the  prisms  of  the  enamel  exhibited  a 
very  distinct  brown  pigmentation. 


6o 


DENTAL    PATHOLOGY  AND    PRACTICE. 


In  a  second  case,  that  of  a  permanent  cuspid,  also  on  the  buccal 
surface  near  the  edge,  a  protrusion  of  dentine  was  observed,  occu- 
pying nearly  one-half  of  the  breadth  of  the  enamel.  (See  Fig.  34.) 
This  protrusion  was  of  a  conical  shape,  and  without  a  distinct  bound- 
ary, but  blended  with  an  oblong  field  of  enamel  of  quite  remarkable 
structure.  The  dentinal  canaliculi  exhibited  at  their  peripheral  por- 
tions numerous  bifurcations,  and  terminated  in  small  pear-shaped 
enlargements,  many  of  which  could  be  traced  in  connection  with 
dentinal  fibers,  whereas  the  most  peripheral  ones,  owing  to  their 
devious  course,  looked  isolated.     The  adjacent  enamel  showed  but 

Fig.  33. 


Protrusion  of  Dentine  into  Enamel. 
E,  enamel ;  D,  dentine  ;  H,  hill  of  dentine  with  fluted  summit ;  P,  protoplasmic  bodies  in  the 
dentine.     Magnified  400  diameters. 


very  indistinct  rods,  the  main  mass  of  the  enamel  being  occupied  by 
brownish  globular  fields,  separated  from  one  another  by  irregular  in- 
terstices closely  resembling  the  interglobular  spaces  of  dentine, 
though  of  considerably  smaller  size.  The  deepest  pigmentation 
and  the  largest  number  of  such  interprismatic  spaces  occurred  along 
the  periphery  of  this  anomalous  formation,  especially  toward  the 
outer  surface  of  the  enamel.  The  vicinity  of  the  enamel  proper  was 
marked  by  the  presence  of  slightly  pigmented  rods,  more  wavy  in 
their  course  than  normal.  Toward  the  dentine  the  anomalous  forma- 
tion was  sloping,  and  the  line  of  demarkation  between  the  normal  and 
anomalous  enamel  exhibited  either  brown  and  very  wavy  prisms  or 


PATHOLOGY  OF  THE  ENAMEL. 


6l 


small  interprismatic  spaces,  decreasing  in  diameter  the  nearer  they 
approached  to  the  dentine.  I  wish  to  emphasize  and  call  particular 
attention  to  the  fact  that  the  dentine  of  this  tooth  was  nowhere  tra- 
versed by  interglobular  spaces  ;  the  anomalous  structure  being  con- 
fined to  the  enamel. 

Fig.  34. 


Protrusion  oi-'  Dentine  into  Pathological  Enamkl. 
£,  enamel;  Z?,  dentine  ;  G,  granular  enamel;  ^,  summit  of  the  dentine;  6',  sloping  borders 
of  the  granular  enamel.    Magnified  200  diameters. 


II. — Stratification  of  Enamel. 

It  is  known  that  dentine,  without  exhibiting  pathological  features, 
is  sometimes  composed  of  strata,  more  or  less  distinctly  marked, 
slightly  deviating  from  its  normal  sti'ucture,  and  altogether  different 
from  the  formations  known  as  secondary  dentine.  We  often  meet 
with  similar  formations  in  the  enamel.  We  observe  layers  varying 
in  width  and  more  or  less  sharply  marked  by  a  straight  line,  which  in 
longitudinal  sections  of  teeth  exhibit  concentric  layers,  the  broadest 
portion  always  corresponding  to  the  cusps,  the  narrowest  always  to 
the  neck,  of  the  tooth.      (See  Fig.  35. ) 

At  the  outer  periphery  of  the  enamel  there  may  occur  strata,  which, 


62 


DENTAL    PATHOLOGY    AND    PRACTICE. 
Fig.  35. 


.  Diagram  of  Stratification  of  Enamel. 
P, pulp-chamber;  D,  dentine  ;    CL\  CL-,  CL\  CL\  cusp-layers  of  enamel ;  NL\  NL^-,  neck- 
layers  of  enamel. 


PATHOLOGY  OF  THE  ENAMEL.  63 

contrary  to  the  general  structure  as  above  described,  are  broadest 
toward  the  neck  and  narrowest  toward  the  cusp,  though  never 
reaching  its  summit.  In  transverse  sections  the  enamel  shows  simply 
concentric  lines  separating  from  one  another  layers  of  greatly  varying 
diameters.  With  higher  powers  of  the  microscope  we  ascertain  the 
fact  that  the  lines  of  stratification,  as  a  rule,  do  not  alter  the  general 
course  of  the  enamel-prisms, — in  other  words,  a  single  enamel-prism 
will  show  an  oblique  line  of  demarkation,  corresponding  to  the  gen- 
eral line  of  stratification,  without  being  altered  in  its  construction  or 
its  course.  An  exception  to  this  rule  occurs  only  at  the  peripheral 
portions  of  enamjel,  occupied  by  the  tapering  ends  of  the  above- 
described  secondary  strata,  which  I  would  like  to  term  neck-layers,  in 
contradistinction  to  the  central  cusp-layers.  The  tapering  ends  of  the 
neck- layers  may  exhibit  enamel-rods,  almost  parallel  with  the  surface 
of  the  enamel,  a  feature  which  is  never  seen  at  the  outer  periphery  of 
the  cusp-layers,  where  the  enamel-rods  are  invariably  directed  more 
or  less  vertically  to  the  surface. 

A  knowledge  of  the  stratification  of  the  enamel  is  of  the  utmost 
importance  for  the  understanding  of  its  pigmentation  and  granulation. 
As  I  will  show  later  on,  both  the  pigmentation  and  granulation  corre- 
spond to  the  general  strata  of  the  enamel,  showing  in  longitudinal 
sections  of  teeth  a  fan-like  appearance. 

It  can  scarcely  be  doubted  that  the  stratification  of  this  tissue  is 
in  close  relation  to  the  history  of  its  development.  We  know  that 
the  first  appearing  enamel-cap  of  temporary  teeth,  in  the  seventh 
month  of  intra-uterine  life,  has  the  configuration  of  the  innermost 
cusp-layer, — i.e.,  it  is  broadest  in  the  direction  of  the  future  cusp,  and 
tapers  toward  the  future  neck  of  the  tooth.  It  seems  reasonable  to 
assume  that  the  subsequent  layers  of  enamel  form  on  the  plan  of 
the  first,  but  there  may  be  a  temporary  stoppage  of  construction, 
due  perhaps  to  slight  ailments  of  the  mother  before  delivery  of  the 
child,  or  slight  ailments  of  the  infant  after  delivery,  which  cause 
interruptions  in  its  organization.  Slight  ailments  of  a  general  nature 
will  not  interfere  with  the  final  result  of  an  otherwise  sound  enamel  ; 
whereas  severe  ailments,  particularly  those  of  a  local  character,  may 
lead  not  only  to  stratification,  but  to  a  decidedly  pathological  condi- 
tion, which  I  have  before  called  pigmentation  and  granulation.  These 
conditions  invariably  involve  a  deficient  deposition  of  lime-salts. 

III. — Anomalous  Arrangements  of  the  Enamel-Rods. 

In  normal  enamel  longitudinal  sections  will,  in  the  majority  of 
cases,  exhibit  slightly  wavy  rods,  interlaced  by  comparatively  small 
bundles,  cut  in  a  transverse  direction.  Toward  the  periphery  the 
curvatures  of  the  rods  gradually  become  less,    until,    close  to  the 


64 


DENTAL  PATHOLOGY  AND  PRACTICE. 


surface,  they  present  a  nearly  straight  course.  I  have  never  seen 
transverse  sections  of  enamel-rods  directly  in  contact  with  the  inter- 
zonal layer. 

Deviations  from  this  rule  seem  to  be  rare,  and  then  the  enamel- 
rods  seem  to  lack  all  regularity  in  their  arrangement.  It  may  occur 
that  close  to  the  interzonal  layer  the  enamel-rods  show  extensive 
fields  occupied  by  these  transverse  sections,  which  gradually  blend 
with  oblique  and  longitudinal,  producing  a  wavy  appearance,  to  such 
an  extent  that  beautiful  figures  arise,  reminding  one  of  the  grain  of 
lignum-vitcB .     (See  Fig.  36.)     Still  more  complicated  figures  arise  if 


Fig.  36. 


Extremely  Irregular  Course  of  Rods  in  Slightly  Pigmented  Enamel. 
The  longitudinal  rods  deviating  to  a  great  extent  from  the  field  of  the  specimen,  show  oblique 
and  transverse  sections.    The  interstices  are  widened  and  contain  very  conspicuous  enamel- 
fibers.    Magnified  800  diameters. 

the  transverse  bars  of  the  longitudinal  rods  are  unusually  conspicuous. 
In  such  enamel  it  may  occur  that  the  curvatures  of  the  rods  remain 
very  marked  up  to  the  surface  ;  and  consequently  groups  of  transverse 
sections  may  be  seen  directly  at  the  outer  surface. 

Enamel  of  this  description  may  be  seen  on  only  one  portion  of  the 
tooth,  while  the  remainder  is  normal.  With  this  curly  appearance  of 
the  enamel-rods,  in  all  my  specimens,  pigmentation  is  combined 
as  a  marked  feature,  and  the  interstices  between  the  rods  are  a  trifle 


PATHOLOGY    OF   THE    ENAMEL.  65 

wider  than  normal.  Both  of  the  latter  features  must  involve  a  defi- 
cient calcification,  and  consequently  extreme  brittleness.  It  is  very 
difficult  to  obtain  perfect  specimens  of  such  enamel.  The  dentine 
subjacent  to  such  anomalous  formations  is  freely  supplied  with  inter- 
globular spaces  (which  is  likewise  a  sign  of  deficient  calcification). 

IV. — Deficient   Calcification   of  the   Enamel   without 
Pigmentation. 

The  friability  alluded  to  under  the  previous  heading  is  in  some  in- 
stances very  marked, — so  much  so,  in  fact,  that  it  is  impossible  to  ob- 
tain an  unbroken  slab  of  a  tooth  even  with  the  finest  grinding-stones. 
With  low  powers  of  the  microscope  we  observe  that  the  broken  ends 
of  the  enamel-rods  look  as  if  corroded,  or  as  if  some  of  them  had 
been  displaced  or  torn  off  in  the  process  of  grinding.  Neither  pig- 
mentation nor  an  anomalous  course  of  the  enamel-rods  is  necessarily 
connected  with  such  a  condition  of  the  tooth.  The  most  striking 
feature,  however,  which  is  visible  even  with  low  powers,  is  that  the 
enamel-rods  are  unusually  narrow,  the  interstices  between  them 
unusually  wide,  and  their  tenants,  the  enamel-fibers,  very  prominent. 
The  cross-lines  of  the  enamel-rods  are  likewise  considerably  widened 
and  irregular,  so  that  the  fields  of  basis-substance  look  unusually 
small  and  irregular.  The  reticulum  in  the  immediate  vicinity  of  the 
interzonal  layer  is  also  unusually  prominent. 

Such  a  condition  of  the  enamel  may  occur  both  in  temporary  and 
permanent  teeth,  and  may  be  combined  with  pigmentation.  It  is  a 
feature  of  such  deficient  enamel  that  it  readily  stains  with  an  ammo- 
niacal  solution  of  carmine,  which  normal  enamel  will  never  do.  The 
subjacent  dentine,  under  such  conditions,  may  either  be  perfectly  de- 
veloped, as  before  stated,  or  be  deficient  in  its  formation,  as  shown 
by  the  presence  of  more  or  less  numerous  interglobular  spaces. 

All  clinicians  have  observed  congenital  white  or  yellow  spots  in  the 
enamel  of  teeth,  which  if  broken  into  are  found  to  be  of  the  consist- 
ence of  chalk.  Such  spots  have  been  termed  "white  decay," 
although  they  do  not  correspond  to  the  process  of  caries  as  we  usu- 
ally understand  it.  They  really  mean  nothing  but  deficient  calcifica- 
tion. Again,  all  clinicians  have  seen  teeth  across  which  a  row  of  pit- 
holes  exists,  where  in  many  instances  in  the  bottom  of  the  depressions 
no  enamel  is  to  be  found.  This  condition  is  also  always  congenital, 
and  closely  related  in  its  origin  to  pigmentation  and  the  white  or 
yellow  spots.  In  other  instances  an  originally  smooth  enamel  is  mu- 
tilated mechanically  by  the  process  of  mastication,  with  the  result  of 
loss  of  substance,  leaving  abruptly  broken,  jagged  edges.  Again,  we 
see  teeth  with  a  great  portion  of  their  crowns  covered,  in  place  of 
enamel,  by  a  brownish-yellow  substance  which  is  so  soft  as  to  be  easily 

6 


66 


DENTAL    PATHOLOGY    AND    PRACTICE. 


removed,  leaving  the  dentine  bare  of  its  covering  and  extremely  sen- 
sitive to  the  touch  of  an  instrument,  the  pressure  of  food  in  masti- 
cation, etc.  These  conditions,  again,  are,  in  most  instances  at  least, 
connected  with  pigmentation  and  the  white  or  yellow  spots.  We 
might  call  them  exaggerated  cases  of  the  same  condition.  Obviously 
these  congenital  defects  are  dependent  upon  deficient  deposition  of 
lime-salts  in  the  basis-substance,  rendering  the  enamel  less  resistant 
and  more  friable. 

V. — Pigmentation  of  Enamel. 

One  of  the  most  common  pathological  conditions  of  the  enamel  is 
its  pigmentation.     Sometimes  it  is  so  slightly  marked  that  the  naked 

Fig.  37. 


EP 


EG 


ER 


Pigmented  and  Granular  Enamel. 
D,  dentine ;  ER,  layer  of  slightly  pigmented  rods  broken  off;  EG,  layer  of  highly  pigmented 
and  granular  enamel ;  EP,  stratified  pigmented  enamel.    Magnified  400  diameters. 

eye  discovers  only  a  slight  yellow-brown  discoloration  ;  in  other 
instances  the  abnormality  is  quite  prominent  and  readily  discernible. 
Specimens  of  such  teeth  under  the  microscope  will  correspondingly 
exhibit  either  a  dim  yellow  tint  in  the  enamel  or  a  very  marked  brown 
discoloration.  The  pigmentation  may  occur  either  in  non-stratified  or 
in  stratified  enamel.  (See  Fig.  37.)  In  the  first  instance  there  is  no  de- 
markation  of  the  brown  spot  toward  the  colorless  enamel  ;  only  faintly- 
marked  oiTshoots  from  the  main  spot,  tapering  toward  the  dentine. 


PATHOLOGY    OF   THE    ENAMEL.  67 

and  running  in  an  oblique  direction,  will  indicate  the  fact  that  pig- 
mentation has  occurred  during  its  formation.  In  the  second  instance, 
on  the  contrary,  where  pigmentation  invades  stratified  enamel,  there 
is  a  close  relationship  between  the  two,  inasmuch  as  the  deepest  stain 
invariably  corresponds  to  the  boundary  line  of  the  strata,  tapering 
toward  the  neck,  and  gradually  fading  toward  the  proximal  end  of 
each  stratum.  Thus,  in  longitudinal  sections,  a  beautiful  fan-like 
configuration  is  produced. 

The  pigmentation  may  invade  all  layers  of  the  enamel,  often  being 
more  marked  in  the  deeper  than  in  the  superficial  portions.  Higher 
powers  of  the  microscope  reveal  the  following  facts  :  First,  that  the 
brown  discoloration  concerns  the  basis-substance  of  the  enamel-rods 
only.  Second,  that  the  interstices  between  the  pigmented  enamel- 
rods  are  widened  in  appearance,  not  due  to  contrast  in  color,  but  to  a 
deficiency  in  the  formation  of  the  basis-substance.  Third,  that  the 
transverse  lines  of  the  enamel-prisms  are  likewise  (at  least  in  many  in- 
stances) enlarged.  Fourth,  that  the  enamel-fibers  and  their  lateral  ofif- 
shoots  are  more  conspicuous  than  in  normal  enamel,  and  more  so  even 
than  in  the  enamel  of  temporary  teeth,  and  in  many  places  distinctly 
beaded.  Pigmented  portions  of  the  enamel  are  very  prone  to  take 
up  a  red  stain  on  being  treated  with  an  ammoniacal  carmine  solution. 

As  to  the  origin  of  the  brown  discoloration,  I  have  to  say,  as  a 
suggestion  simply,  that  at  the  time  of  the  formation  of  this  tissue 
there  must  have  been  a  disturbance  in  the  enamel-organ  which  in- 
terfered with  the  proper  building  up  of  the  basis-substance  and  the 
deposition  of  lime-salts.  What  this  disturbance  really  was,  I  am 
unable  to  say.  All  pigments  of  the  body  depend  upon  and  are 
closely  related  to  the  coloring-matter  of  the  blood.  I  am  loath, 
however,  at  this  time,  to  attribute  pigmentation  of  enamel  to  the 
extravasation  of  blood-corpuscles  or  diffusion  of  the  coloring-matter 
of  the  blood.  Careful  studies  in  the  history  of  the  development  of 
this  tissue  must  be  made  before  an  attempt  at  a  solution  of  this 
question  will  be  admissible.  One  point  I  am  positive  about,  how- 
ever, is  that  this  pigmentation  is  congenital,  invading  temporary  as 
well  as  permanent  teeth.  Acquired  pigmentation  of  enamel  seems 
to  be  of  comparatively  rare  occurrence,  except  as  a  result  of  caries. 
I  have  seen  pigmentations  of  its  surface,  of  a  deep  orange  color, 
not  penetrating  the  enamel-tissue  in  the  least.  Caries  on  the  surface 
often  causes  an  orange  discoloration,  diffused  and  fading  toward  the 
normal  portions.  Several  of  my  specimens  plainly  show  an  invasion 
of  the  enamel  by  caries,  on  spots  pigmented  congenitally  ;  second- 
arily, an  orange  diffused  discoloration  has  taken  place,  which  is 
prone  to  take  up  the  carmine  stain  before  referred  to  ;  thus  beautiful 
shadings  of  brown,  orange,  and  red  are  to  be  seen,  the  brown  being 


68  DENTAL  PATHOLOGY  AND  PRACTICE. 

congenital,  the  orange  acquired,  and  the  red  artificial.  What  chem- 
ical may  lead  to  an  acquired  pigmentation  or  discoloration  of  the 
enamel  I  cannot  say. 

VI. — Granulation  of  Enamel. 

Under  this  heading  I  propose  to  describe  a  very  peculiar  patho- 
logical condition  of  this  tissue,  which  my  specimens  seem  to  indicate 
as  being  by  no  means  rare.  It  consists  of  pear,  spindle,  and  club- 
shaped  spaces  in  the  interior  of  the  substance  of  the  enamel.  Such 
spaces  have  heretofore  been  shown  to  exist  at  the  junction  of  the 
dentine  and  enamel  only.  They  may  appear  in  pigmented,  and 
invariably  do  in  stratified  enamel ;  the  stratification  in  the  latter  in- 
stance being  due  to  their  presence.  Club-shaped  spaces  may  appear 
at  the  distal  boundary  of  one  of  the  cusp-layers,  or  there  may  be 
several  rows  of  such  spaces,  varying  in  extent  and  degree,  but  it 
sometimes  occurs  that  only  the  outermost  cusp  or  neck  layers  are 
freely  supplied  with  them,  whereas  the  remainder  of  the  enamel  is 
normal  or  more  or  less  pigmented. 

Higher  powers  of  the  microscope  demonstrate  that  the  spaces 
are  enlargements  of  the  interstices  between  the  prisms  and  the 
tenants  of  the  interstices.  The  enamel-fibers  are  in  direct  connec- 
tion with  the  contents  of  the  spaces, — i.e.,  with  living  matter.  The 
spaces,  accordingly,  at  their  stem-like  beginnings,  run  parallel  with 
the  interstices  ;  but  in  their  broader  portions  they  may  cross  the 
enamel-prisms  in  different  directions.  If  they  are  few  in  number 
they  may  protrude  from  the  boundary  line  of  a  cusp-layer,  and  pen- 
etrate the  adjacent  cusp-layer  obliquely  to  the  main  direction  of  the 
enamel-rods.  In  the  case  illustrated  (Fig.  38)  I  could  trace  the 
connections  of  the  enamel-fibers  even  with  the  club-shaped  ends  pro- 
jecting into  the  neighboring  cusp-layer.  If  these  spaces  are  present 
in  large  numbers,  the  enamel,  with  lower  powers  of  the  microscope, 
will  look  dark  and  granular  ;  hence  the  name  ' '  granulation  of 
enamel"  which  I  have  given  it. 

Fig.  34  represents  this  condition  of  granulated  enamel  with  a  low 
power.     Fig.  38  shows  the  condition  under  a  high  power. 

In  stratified  and  granular  enamel,  single  strata  may  be  produced 
by  an  interruption  of  the  pigmented  enamel-rods,  by  convex  ends 
of  the  club-shaped  spaces  directed  toward  the  adjacent  peripheral 
cusp-layer.     (See  Fig.  37.) 

The  inierprismatic  spaces  of  the  enamel  bear  some  resemblance 
to  the  interglobular  spaces  of  the  dentine.  One  of  my  specimens 
shows  both  conditions  in  a  highly-marked  degree.  Whenever  these 
interprismatic  spaces  are  present  along  the  border  of  a  cusp-layer  they 
considerably  lessen  the  degree  of  consistence  of  the  enamel,  which, 


PATHOLOGY    OF   THE   ENAMEL. 


69 


upon  being  ground,  breaks  off  easily  along  the  dark  granular  line. 
The  nature  of  the  interprismatic  spaces  is  plain  enough.  They  mean 
an  incomplete  formation  of  the  enamel,  owing  to  some  deficiency  of 
function  in  the  enamel-organ  during  its  formation.  Obviously  not 
only  is  the  basis-substance  deficient,  but  the  amount  of  lime-salts  is 
also  considerably  less  than  normal  ;  hence  the  brittleness  and  prone- 
ness  to  decay. 

Under  the  foregoing  headings  I  have  described  a  number  of  patho- 
logical conditions  of  the  enamel,  which,  at  least  so  far  as  stratifica- 
tion, pigmentation,  and  granulation  are  concerned,  mean  a  deficient 

Fig.  38. 


Intergranular  and  Slightly  Pigmented  Enamel. 
Club,  spindle,  pear-shaped,  and  irregular  spaces  at  the  boundary  of  a  cusp-layer  in  the  middle 
of  enamel.    Magnified  800  diameters. 

formation  of  the  basis-substance,  together  with  decreased  deposition 
of  lime-salts.  These  conditions  are,  in  my  judgment,  of  the  utmost 
importance  in  the  etiology  of  caries.  Ailments  either  of  the  mother 
during  gestation  or  of  the  infant  in  the  earliest  periods  of  life  obvi- 
ously cause  such  anomalies  in  this  tissue.  These  ailments  are  known 
to  occur  far  more  frequently  in  refined  people,  debilitated,  as  it  were, 
by  civilization,  than  in  strong,  hard-working,  plain-living  people,  con- 
tinually engaged  in  the  struggle  for  life.  Thus,  I  have  directly  demon- 
strated and  anatomically  shown,  in  a  measure,  at  least,  the  reasons 
why  refined  people  are  far  more  subject  to  caries  of  the  teeth  than 
people  lacking  such  refinement. 


7©  DENTAL  PATHOLOGY  AND  PRACTICE. 

CHAPTER    VII. 

CARIES  OF  HUMAN  TEETH.* 

After  having  studied  this  subject  more  or  less  continuously,  both 
practically  and  microscopically,  for  the  past  sixteen  years,  I  have  still 
to  adhere  essentially  to  the  views  published  by  me  in  1879. 

Having  for  several  years  previously  held  opinions  differing  more  or 
less  from  those  of  any  writer  upon  this  subject,  though  without  defi- 
nite data  to  stand  upon,  I  concluded  to  investigate  the  subject  thor- 
oughly, and  thus  to  either  prove  my  theories  correct  or  abandon  them 
{qx  facts  which  I  expected  to  establish.  Very  much  to  my  gratifica- 
tion, my  researches  confirmed  my  former  views,  with  very  little  if  any 
variance.  Notwithstanding  the  fact  that  nearly  all  investigators  to 
whose  writings  access  was  had,  accounted  for  the  decay  of  teeth  in 
what  seemed  apparently  to  the  profession  a  satisfactory  way,  still  there 
were  practical  facts  which  led  me  to  view  the  subject  differently,  and 
for  which  it  was  difficult  to  account  from  their  standpoint.  In  attempt- 
ing to  explain  these  facts,  I  have  been  careful  to  make  no  statement 
which  I  am  not  able  to  prove  to  any  one  who  will  take  the  trouble  to 
study  the  specimens  carefully  under  the  microscope. 

Dr.  C.  F.  W.  Bodecker  had  then  recently  discovered  and  described 
some  important  though  previously  unnoted  facts  in  the  minute 
structure  of  human  teeth.  My  own  researches  are  corroborative  of 
Bodecker' s  discoveries,  which  are  here  briefly  recapitulated  in  order 
to  a  full  understanding  of  the  morbid  processes,  which  is  possible  only 
upon  a  correct  knowledge  of  the  normal  conditions. 

Since  Dr.  C.  Heitzmann  brought  to  evidence  that,  with  the  exception 
of  dry  horny  tissue  (epidermis,  nails,  and  hair),  all  other  tissues  of 
the  living  body  ai^  endowed  with  life,  and  that  the  presence  of  living 
matter  is  demonstrable  not  only  in  the  formerly  so-called  cells,  but 
also  in  the  basis-substance  (matrix),  the  question  rose  whether  a 
normal  tooth,  attached  to  a  living  body,  was  not  in  itself  possessed 
of  this  same  living  matter.  It  was  to  be  expected,  judging  from  the 
phenomena  of  growth,  of  decay,  of  restitution,  etc.,  that  a  tooth 
was  provided  with  such  living  matter  just  as  well  as  bone,  which  it 
resembles  so  greatly  in  its  minute  structure  ;  but  the  full  evidence  of 
its  presence  in  the  tissues  of  the  tooth  was  first  demonstrated  by  Dr. 
Bodecker. 

The  dentine  is  traversed  by  innumerable  canaliculi,  which  ramify 
both  toward  the  enamel  and  the  cement.  Each  canaliculus  con- 
tains a  delicate  fiber  of  living  matter,  which  is  in  direct  connection 

*  Abbott,  Dental  Cosmos,  1879. 


CARIES    OF    HUMAN    TEETH.  7 1 

with  the  protoplasmic  formations  within  the  pulp-cavity,  with  the  off- 
shoots of  the  cement-corpuscles,  and  with  the  fibers  between  the 
enamel-rods.  Every  dentine-fiber  sends  innumerable  delicate  conical 
threads  through  the  cavity  of  the  canaliculus  into  the  basis-substance 
between  the  canaliculi,  where  a  very  minute  net-work  of  living  matter 
is  present,  uniting  the  dentinal  fibers  with  one  another  throughout  the 
entire  tissue  of  the  dentine.  The  basis-substance  is  analogous  to  that 
of  bone,  therefore  glue-giving,  and  at  the  same  time  infiltrated  with 
lime-salts.  Around  each  dentinal  canaliculus  the  basis-substance  is 
denser  than  between  the  canaliculi. 

The  cement  is  identical  in  every  respect  with  bone  ;  its  basis-sub- 
stance is  traversed  by  larger  cavities,  which  contain  nucleated  proto- 
plasmic bodies, — the  cement- corpuscles.  From  these  arise  larger 
offshoots  in  a  radiated  arrangement,  and  the  protoplasmic  body  as 
well  as  all  its  larger  ramifying  offshoots  send  delicate  offshoots  of 
living  matter  into  the  basis-substance,  which  latter  is  pierced  by  a 
net-work  of  living  matter,  this  being  in  uninterrupted  connection  with 
the  net- work  within  the  basis-substance  of  the  dentine,  the  boundary 
being  termed,  formerly,  the  interglobular  space  ;  by  Dr.  Bodecker, 
"  interzonal  layer." 

The  enamel  is  provided  between  its  polyhedral  rods  with  very 
slender  fibers  of  living  matter,  which  also  send  extremely  delicate 
offshoots  into  the  basis-substance  of  the  rods.  These  offshoots  traverse 
the  cement-substance  between  the  rods,  and  form  an  extremely  minute 
net-work  of  living  matter  within  the  rods  themselves,  its  meshes  being 
occupied  by  dense  depositions  of  lime-salts.  Again,  the  net- work  of 
living  matter  of  the  enamel  is  in  direct  union  with  that  of  the  dentine, 
and,  at  the  neck  of  the  tooth,  with  the  net-work  of  the  cement. 

From  these  facts  it  necessarily  follows  that  we  must  consider  a  tooth 
which  is  normal  in  its  structure,  and  in  close  connection  through  the 
periosteum  with  the  jaws,  as  a  living  body  ;  consequently,  it  follows 
that  morbid  processes  will  result  in  a  reaction  of  the  living  matter  in 
the  tooth  just  as  well  as  in  bone  or  any  other  living  tissue  of  the  body. 
What  this  reaction  essentially  consists  in  during  the  process  termed 
caries  I  have,  to  my  own  satisfaction  at  least,  pretty  clearly  settled. 
And  it  occurs  to  me  that,  through  my  researches,  new  standpoints 
have  been  revealed  of  considerable  value,  both  for  abstract  science 
and  practical  use. 

Methods. — The  results  obtained  with  regard  to  the  minute  structure 
of  the  teeth  have  been  arrived  at  by  methods  different  from  those  pre- 
viously in  use.  As  a  matter  of  course,  the  specimens  from  dried  teeth, 
which  were  formerly  used  almost  exclusively,  did  not  reveal  any  of 
the  soft  parts  within  the  hard  dental  tissues.  Only  the  frame  of  the 
tissue  was  left,  and  we  may  readily  understand  why  the  investigations 


72  DENTAL  PATHOLOGY  AND  PRACTICE. 

of  the  carious  process  did  not  pass  above  hypotheses  and  specula- 
tions. 

For  preparing  dentine  and  cement,  there  is  no  better  method  known 
than  slow  decalcification  by  means  of  a  one  per  cent,  solution  of 
chromic  acid.  In  my  experience  large  quantities  of  this  solution  are 
needed  for  a  few  teeth.  A  few  drops  of  hydrochloric  acid  may  be 
added  to  the  chromic  acid  solution  every  other  day,  in  order  to  hasten 
the  decalcifying  process.  And  the  solution  itself  should  be  changed 
frequently,  say  once  every  week.  The  process  of  decalcification 
ought  to  proceed  very  slowly  ;  so  much  so,  that  at  least  two  months 
should  be  required  for  preparing  the  superficial  layers  of  the  tooth  for 
cutting  with  a  razor. 

The  teeth  thus  prepared,  after  the  water  had  been  extracted  from 
them  with  strong  alcohol,  I  imbedded  in  paraffin  with  a  small  quan- 
tity of  wax  added.  The  sections  obtained  from  the  specimens  were 
stained  with  carmine,  this  being,  in  my  experience,  the  best  method 
for  the  demonstration  of  the  carious  condition  of  the  tooth.  After 
this  I  mounted  the  specimens  in  glycerin,  diluted  one-half  with  dis- 
tilled water,  and  lastly  inclosed  them  with  ordinary  asphalt  varnish. 

The  enamel  of  teeth  prepared  in  the  foregoing  manner  can  never 
be  cut,  because  it  becomes  extremely  brittle  ;  therefore,  I  was  obliged 
to  resort  for  its  examination  to  the  method  first  practiced  by  Dr. 
Bodecker,  which  consists  essentially  in  grinding  perfectly  fresh  teeth 
down  to  the  necessary  thinness,  always  under  water.  The  thin  slices 
should  be  kept  for  twenty-four  hours  in  a  very  dilute  solution  of 
chromic  acid,  for  decalcification.  A  saturation  of  this  solution  of 
over  one-half  of  one  per  cent,  is  in  my  opinion  deleterious  to  the 
enamel,  which  if  completely  decalcified  shows  only  a  minute  net-work 
of  living  meatier,  as  I  first  observed,  with  no  trace  of  the  enamel-rods 
and  prisms. 

A  little  practice  will  enable  any  one  to  obtain  ground  specimens 
of  a  whole  tooth,  of  such  extreme  delicacy  that  they  are  fit  for  even 
the  highest  magnifying  powers,  over  one  thousand.  A  perfectly 
transparent  condition  should  be  the  main  property  of  a  specimen  of 
a  carious  tooth,  because  only  with  such  specimens  are  we  enabled  to 
study  the  minutest  changes  of  the  tissues  to  our  satisfaction.  Ground 
specimens  can  be  stained  with  carmine  and  mounted  in  the  same  way 
as  those  obtained  by  cutting. 

The  old  method  of  mounting  specimens  of  teeth  in  damar  varnish 
or  Canada  balsam  has  proved  so  very  unsatisfactory,  owing  to  the 
high  degree  of  the  clearing  process,  that  it  has  been  abandoned  by 
our  best  microscopists.  This  method  was  good  enough  for  specimens 
of  dry  teeth,  in  which  the  compartments  in  the  dentine  and  enamel 
were  filled  with  filth  and  air  ;  but  as  we  nowadays  wish  to  see  more  of 


CARIES   OF    HUMAN   TEETH.  73 

the  soft  tissues  within  the  hard  framework,  we  employ  the  only  relia- 
ble methods  as  yet  discovered,  as  described  above. 

Etiology. — Although  the  examination  of  a  carious  tooth  can  reveal 
the  cause  of  the  disease  only  to  a  limited  degree,  I  do  not  hesitate  to 
express  my  conviction  in  this  respect,  on  the  foundation  of  many 
years  of  practical  experience. 

There  is  not  the  slightest  doubt  in  my  mind  as  to  the  origin  of 
caries  of  teeth.  The  first  lesion  under  all  circumstances  is  due  to  the 
action  of  an  acid,  which  in  a  merely  chemical  way  dissolves  out  the 
lime-salts  from  the  enamel.  No  doubt  quite  a  strong  acid  is  neces- 
sary for  decalcification  of  so  solid  a  tissue  as  the  enamel  of  a  tooth. 
And  the  question  often  arises.  Where  does  this  acid  come  from  ? 

First  let  us  take  into  consideration  the  starting-points  of  the  morbid 
process.  I  fear  no  contradiction  on  the  part  of  my  professional  breth- 
ren when  I  say  caries  never  begins  on  the  smooth  surfaces  of  a  tooth, 
which  are  exposed  to  the  friction  of  mastication,  but  always  starts  at 
points  which,  owing  to  their  anatomical  structure,  form  receptacles 
for  food,  etc. ,  or  at  places  between  the  teeth  where,  owing  to  want  of 
cleanliness,  decaying  material  can  accumulate.  It  is  therefore  not  to 
the  friction  between  the  single  teeth  (Salter)  (which,  as  we  know,  is 
possible  to  a  certain  extent  in  the  normal  condition),  but  to  the  acid 
generated  from  the  decaying  material  retained  between  the  two  flat 
or  concave  surfaces  which  the  teeth  present  to  each  other,  that  the 
beginning  of  the  destruction  of  enamel  in  this  locality  is  due. 

That  this  decaying  material  may  be  sought  for  and  found  in  the 
food  I  think  will  hardly  admit  of  a  doubt ;  and,  as  it  occurs  to  me, 
mainly  in  such  kinds  of  food  as  through  their  decomposition  are  apt 
to  produce  an  acid,  not  very  strong,  perhaps,  in  itself,  but  possessing 
a  high  degree  of  affinity  for  lime-salts,  viz,  lactic  acid. 

First  among  the  varieties  of  food  ranks  meat,  which  by  putrefaction 
may  produce  free  lactic  acid  ;  next  are  the  saccharine  materials  ;  and 
last  the  amylaceous,  which  being  converted  into  dextrin  by  the 
action  of  the  saliva,  may  be  transformed,  if  brought  in  contact  with 
putrefying  meat,  into  lactic  acid.  There  is  no  doubt  that  the  or- 
ganic portion  of  teeth,  as  it  advances  to  the  stage  of  decomposition 
in  the  process  of  caries,  plays  a  very  important  part  in  the  formation 
of  this  acid. 

Perhaps  the  sour  decomposition  is  assisted  locally  by  the  action  of 
micrococci  and  leptothrix  ;  although  these  organisms  are  known  to 
prosper  only  in  alkaline,  and  not  in  acid  fluids.  These  vegetable 
organisms  are  present  in  innumerable  quantities  on  the  healthiest 
gum  ;  tartar  is  crowded  with  them.  And  even  in  the  highest  degrees 
of  development  of  tartar  caries  is  absent.  In  fact,  when  decayed 
cavities  in  teeth  become  filled  with  tartar,  the  carious  process  is  as 


74  DENTAL  PATHOLOGY  AND  PRACTICE. 

effectually  stopped  as  It  is  possible  for  it  to  be  when  such  cavities  are 
filled  in  the  most  perfect  manner,  with  gold  or  any  other  favorite 
material.  Hence  I  do  not  consider  the  views  of  those  authors  correct 
who  claim  that  micrococci  and  leptothrix  play  any  important  part  in 
producing,  or  even  supporting,  the  carious  process. 

I  fully  concur,  however,  with  the  views  of  those  who  claim  that  the 
resistance  of  the  teeth  against  caries,  owing  to  their  amount  of  lime- 
salts,  greatly  varies  in  different  people.  The  color  of  the  teeth,  as  is 
well  known,  is  indicative  to  some  extent  of  the  proportion  of  lime-salts 
they  contain.  The  microscope  shows  a  considerable  variety,  with 
regard  to  the  presence  or  the  degree  of  density,  of  that  layer  of  the 
basis-substance  surrounding  the  dentinal  canaliculi.  E.  Neumann 
first  drew  attention  to  this  layer,  which  is  sometimes  so  dense  and  so 
well  defined,  owing  to  its  greater  refracting  power  than  that  of  the  basis- 
substance  between  the  canaliculi,  that  it  may  be  regarded  almost  as 
a  protecting  sheath  to  the  living  matter  within  the  canaliculi.  This 
layer  is  well  marked  even  in  fossil  teeth  ;  it  resists  somewhat  the  action 
of  strong  acids  and  alkalies,  but  it  is  almost  completely  absent  in  a 
number  of  carious  teeth  which  I  have  examined.  I  have  also  re- 
marked that  of  a  number  of  teeth,  treated  in  exactly  the  same  manner 
with  chromic  acid  solution,  some  become  soft  in  a  markedly  shorter 
space  of  time  than  others.  The  general  health  or  constitution  may 
have  considerable  influence  upon  the  quantity  of  lime-salts  deposited 
in  the  basis-substance  of  the  teeth,  although  it  has  been  claimed  that 
people  of  so-called  scrofulous  and  tuberculous  constitutions  on  the 
average  have  better  teeth  than  strong  and  vigorous  persons.  Nations 
of  high  civilization,  which  inevitably  leads  to  bodily  and  mental  depri- 
vation, as  a  rule  have  a  greater  percentage  of  carious  teeth  than  those 
of  a  low  degree  of  culture,  or  of  no  culture  at  all. 

However  this  may  be,  the  fact  that  caries  of  the  teeth  begins  as  a 
chemical  process  will  scarcely,  in  my  opinion,  be  questioned.  On  a 
dead  tooth,  natural  or  artificial,  as  well  as  on  teeth  manufactured 
from  the  dentine  of  the  elephant  or  the  hippopotamus,  the  process 
will  remain,  under  all  circumstances,  a  chemical  one,  assisted  only  by 
the  putrefying  remains  of  the  organic  material  of  the  tooth  ;  while 
on  a  live  tooth  either  acute  or  chronic  reaction-changes  take  place, 
which  I  intend  presently  to  consider. 

Caries  of  Enamel. 

The  clinical  phenomenon  of  caries,  in  its  very  origin,  consists  essen- 
tially in  a  discoloration  of  the  enamel.  A  whitish  or  grayish  spot  on 
the  surface  of  the  enamel  is  indicative  to  an  experienced  eye  of  the 
beginning  of  decay,  the  spot  proving  when  touched  with  an  instru- 
ment to  be  soft  and  crumbly.     Often  a  brown  spot  is  visible  on  the 


CARIES    OF    HUMAN   TEETH.  75 

enamel  as  a  sign  of  the  softening  process.  The  less  pigmentation 
present,  the  more  rapid  is  the  process  of  decay.  On  the  contrary, 
the  more  distinct  the  discoloration,  the  slower  is  the  softening  process. 
Nay,  dark-brown  spots  may  be  present  in  the  enamel  for  many  years 
without  being  followed  by  softening.  The  brown  discoloration,  as 
such,  cannot  be  considered  as  an  essential  feature  of  caries  of  enamel, 
but  it  usually  accompanies  the  carious  process,  and  does  so  the  more 
surely  the  slower  the  morbid  process  runs.  In  microscopic  specimens 
we  meet  with  decayed  pits  in  enamel  without  any  discoloration  of  this 
tissue.  In  other  specimens  we  have  a  very  marked  orange  or  brown 
hue  on  the  decayed  part  as  well  as  in  its  neighborhood,  and  some- 
times scattered  specks  are  to  be  seen  some  considerable  distance  from 
the  diseased  part.  The  brown  discoloration  is  located  in  the  basis- 
substance  of  the  enamel-rods,  the  outlines  of  which  are  much  more 
marked  than  when  in  a  healthy  condition.  The  interstices  between 
the  rods  here  are  plainly  visible  even  with  a  magnifying  power  of 
only  five  hundred  diameters.  This  power  will  reveal  delicate  beaded 
fibers  of  living  matter  within  the  interstices,  which  in  healthy  enamel 
cannot  be  seen  distinctly  with  a  lower  power  than  eight  hundred  to  one 
thousand.  Besides  the  discoloration,  no  material  changes  are  seen 
on  the  enamel-rods. 

To  what  process  the  pigmentation  of  the  enamel  is  due  I  cannot 
say,  but  it  occurs  to  me  that  we  have  no  right  to  look  upon  this 
process  as  a  merely  chemical  reaction  upon  the  basis-substance  of  the 
rods.  That  in  fact  it  is  the  basis-substance  holding  the  pigment,  and 
not  the  lime-salts  deposited  therein,  is  proven  by  specimens  from  which 
the  lime-salts  have  been  extracted  to  a  considerable  extent  by  chromic 
acid,  and  which  still  show  the  brown  stain.  I  dare  say  that  this 
brown  discoloration  is  a  strong  proof  of  the  presence  of  life  in  the 
enamel,  as  in  teeth  where  the  pulps  are  dead  such  stains  never  appear, 
nor  can  they  be  produced  by  artificial  means.  The  process  of  decay 
in  the  enamel  can  best  be  studied  on  superficial  erosions  of  the  same, 
a  sample  of  which  I  have  illustrated.  In  this  instance  the  brown 
discoloration  of  the  decayed  part  was  but  trifling,  and  entirely  absent 
in  its  vicinity,  so  that  we  have  to  consider  it  as  a  case  of  acute  caries. 
We  see  at  E,  E,  Fig.  39,  the  unchanged  enamel  partly  deprived  of  its 
lime-salts.  Toward  the  periphery  a  zone  appears  in  which  the  enamel- 
rods  are  spotted,  evidently  owing  to  their  partial  decalcification. 
Close  to  this  and  immediately  below  the  decayed  part  (see  P,  P)  a 
zone  is  visible  in  which  the  enamel  is  granular,  and  looks  precisely  like 
normal  enamel  from  which,  by  a  somewhat  stronger  solution  of  chromic 
acid,  the  lime-salts  have  been  dissolved  out.  Here  the  protoplasmic 
condition  of  the  enamel  is  re-established  simply  by  decalcification, 
and  there  is  no  doubt  that  this  is  the  very  condition  of  the  enamel 


76  DENTAL    PATHOLOGY   AND    PRACTICE. 

by  which  the  white  spot  is  produced  upon  the  surface  while  the  tooth 
is  still  in  the  jaw.  On  the  boundary  of  the  enamel  we  see  a  shallow 
depression  (C)  filled  with  protoplasmic  bodies,  which  represent  either 
complete  enamel-prisms  or  lumps  of  such  prisms.  All  these  proto- 
plasmic formations  are  united  to  one  another  by  delicate  threads  ;  they 
exhibit  but  a  slight  brown  discoloration,  readily  imbibe  carmine,  and 
if  the  specimen  be  stained  with  a  half  per  cent,  solution  of  chlorid  of 
gold  these  bodies  assume  a  dark-blue  tinge,  while  the  unchanged 
enamel  is  but  little  affected  by  this  reagent.  On  the  outermost 
layer  we  see  several  flat  epithelial  bodies  (N)  attached  to  the  proto- 
plasm, which  in  the  transverse  section  look  irregularly  spindle-shaped, 
.and  are  possibly  the  remnants  of  the  so-called  Nasmyth's  membrane, 

Fig.  39. 

V 

z 


.  1 .      --i.     _ 


r^^  ^--/.       j     :    \ 


i 

1 


-i  -      .     ■ '        '  '    -     -^ 


c-  -Jt  J* 


or  enamel-cuticle.  On  the  level  of  the  enamel  we  also  recognize 
such  flat  epithelia  (/,,  Z,).  Beneath  them  on  the  right  side  of  the 
drawing  there  is  present  a  zone  of  decalcified  enamel,  while  on  the 
left  side  the  division  into  protoplasmic  bodies  is  fully  accomplished. 

Not  a  trace  of  micrococci  or  of  leptothrix  is  visible  in  or  above  the 
decayed  pit  of  the  enamel,  which  again  proves  that  these  organisms 
do  not  play  any  important  part  in  the  process  of  caries  ;  at  least,  do 
not  materially  interfere  with  the  tooth  in  its  normal  condition. 

The  way  in  which  the  caries  proceeds  downward  is  plainly  shown 
by  the  figure.  There  are  small,  irregular,  bay-like  excavations  on 
its  boundary,  and  in  the  midst  of  the  decayed  part  a  wedge-shaped 
elongation  is  running  downward  into  the  softened  enamel.  The 
shape  in  which  caries  appears  in  the  enamel,  however,  varies  greatly. 


PLATE  A. 


CARIOUS  ENAMEL,    LONGITUDINAL  SECTION. 


a,  a,  Normal  enamel ;  h,  h,  disorganized  condition  of  enamel,  show- 
ing marked  inflammatory  reaction. 

X  600. 


CARIES    OF    HUMAN    TEETH. 


77 


Besides  the  wedge  shape  as  illustrated  in  the  wood-cut,  caries  pro- 
ceeds in  the  form  of  shallow  or  conical  excavations,  excavations  with 
abrupt  walls,  fissures,  and  grooves.  On  the  bottom  of  the  main 
excavation  we  sometimes  see  a  smaller  cavity,  having  either  a  narrow 
or  wide  communication  with  the  main  decayed  mass. 

Besides  the  peculiar  medullary  elements  forming  the  contents  of  a 
carious  cavity  of  the  enamel  in  its  initial  stage,  I  have  not  very  rarely 
met  with  dark-brown,  irregularly-shaped  clusters  filling  the  entire 
cavity.  How  such  changes  of  medullary  corpuscles  are  produced  I 
am  unable  to  say,  although  it  seems  to  be  kindred  to  the  so-called 
colloid  or  hyaloid  metamorphosis  which  we  observe  in  other  tissues, 
the  only  difference  being  that  in  caries  the  colloid  clusters  are  deeply 
saturated  with  a  uniform  brown  pigment,  the  origin  of  which,  as 
mentioned  above,  is  unknown. 


Caries  of  Dentine. 

Upon  examining  a  large  number  of  teeth  with  carious  dentine,  we 
are  struck  by  conditions  to  the  presence  of  which  but  few  observers 
have  drawn  attention.  Sometimes  the  dentine,  when  attacked  by 
caries,  looks  but  little  changed  on  its  periphery.  A  narrow  zone  of 
yellowish    color    forms    the    boundary    toward    irregular,     shallow 

Fig.  40. 


^:*:^M-^^'^5?St«i^ 


excavations.  (See  Fig.  40,  a.)  At  other  times,  besides  the  bay-like 
excavations  on  the  periphery,  there  are  visible  elongations,  cylin- 
drical, conical,  pear-shaped,  or  leaf-like,  passing  down  into  the 
dentine  to  varying  depths.  (See  Fig.  40,  b.')  There  is  no  doubt 
that  this  form  of  decay  of  the  dentine  occurs  with  the  least  prelimi- 
nary changes  of  the  tissues  ;  it  evidently  runs  a  slow  course,  and  I 
feel  justified  in  calling  it  chronic.  It  seems  evident  that  decay  of  a 
tooth  assumes  an  acute  or  a  chronic  form  just  in  proportion  to  its  per- 
fect or  imperfect  calcification.  Dead  teeth  in  which  the  pulps  have 
been  destroyed  either  by  necrosis  as  a  natural  process,  or  by  artificial 


78  DENTAL    PATHOLOGY   AND    PRACTICE. 

means  with  caustics,  very  frequently  run  this  kind  of  slow  or  chronic 
decay.  The  decay  of  artificial  teeth,  either  human  or  ivory,  in  all 
probability  runs  either  an  acute  or  a  chronic  course,  according  to  the 
amount  of  lime-salts  infiltrated  into  the  glue-giving  basis-substance. 

I  have  examined  a  piece  of  a  hippopotamus  tooth  which  was  worn 
in  the  mouth  of  a  patient  for  a  period  of  about  one  year,  upon  which  a 
spot  about  the  size  of  a  hemp-seed  became  decayed.  I  softened  this 
piece  with  chromic  acid  solution,  imbedded  it  in  paraffin  and  wax,  and 
cut  thin  sections  with  a  razor.  On  the  bottom  of  the  decayed  pit  numer- 
ous conical  spots  appeared  running  downward  into  the  dentine,  char- 
acterized by  the  absence  of  coloring  matter  in  specimens  stained  with 
carmine.  Aside  from  this  no  material  change  was  observable;  even  the 
dentinal  canaliculi  did  not  look  enlarged.  The  bottom  of  the  carious 
cavity  was  covered  with  a  layer  of  finely  granular,  evidently  disinte- 
grated, organic  material,  and  above  this  the  masses  ordinarily  filling 
carious  cavities  in  teeth,  viz,  micrococci  and  leptothrix,  were  visible. 

In  chronic  caries  the  process  is  principally  a  chemical  one,  which  is 
assisted  by  putrefaction  of  the  organic  constituents  of  the  tooth. 
Here  first  the  solution  of  the  lime-salts  of  the  dentine  takes  place, 
either  along  the  bay-like  excavations  or  in  the  shape  of  longitudinal  de- 
pressions. Very  slight  if  any  reaction  follows  this  process.  The  glue- 
giving  basis-substance  being  deprived  of  its  lime-salts  shows  a  yellow 
discoloration,  and  only  traces  of  the  dentinal  canaliculi.  The  basis- 
substance  then  breaks  down  into  an  indistinct  granular  mass,  which  is 
immediately  filled  with  a  new  growth  of  low  vegetable  organisms,  viz, 
micrococci  and  leptothrix. 

My  specimens  plainly  show  that  these  organisms  are  not  the  ad- 
vance guard  in  the  process  of  decay.  The  first  change  that  takes 
place  is  exposure  of  the  basis-substance  by  the  chemical  action  of 
some  acid,  independent  of  the  organisms  referred  to,  which  come  to 
view  only  after  complete  disintegration  of  the  basis-substance.  I  never 
have  seen  the  penetration  of  these  organisms  into  the  dentinal  can- 
aliculi until  a  thorough  decalcification  of  ihe  basis -substance  had 
taken  place.  No  doubt,  however,  the  decayed  mass  itself  may  be 
crowded  with  such  organisms.  In  the  great  majority  of  my  speci- 
mens I  have  met  with  formations  on  the  diseased  boundary  of  the 
dentine  which  demonstrate  a  considerable  degree  of  reaction,  pro- 
duced by  the  irritating  power  of  the  same  agent  to  which  the  lime- 
salts  of  the  dentine  yield.  In  fact,  this  was  the  case  in  all  teeth 
which  were  alive  when  attacked  by  the  carious  process,  or  rather 
when  removed  from  the  jaws.  On  the  boundary  of  this  process  we 
see  irregularly-shaped  elongations  running  a  certain  depth  into  the 
tissue  of  the  dentine.  The  more  superficial  the  elongations  are,  the 
surer  the  morbid  process  may  be  termed  a  slow  one  ;  and,  on  the  con- 


CARIES    OF    HUMAN    TEETH. 


79 


trary,  the  deeper  the  elongations,  the  more  certain  we  may  be  that  the 
morbid  process  has  advanced  rapidly.  The  elongations  mainly  have 
the  shape  of  fissures  filled  with  a  dark  granular  material,  if  viewed 
with  a  low  power.  These  fissures  run  independently  of  the  direction 
of  the  dentinal  canaliculi  ;  nay,  very  often  cross  them.  (See  Fig.  41, 
<2,  a.)  In  the  specimens  they  look  as  a  rule  as  if  communicating  with 
one  another,  and  also  directly  or  indirectly  with  the  decayed  outer 
surface.  Sometimes  the  fissures  look  completely  isolated,  though  we 
may  assume  that  they  are  separated  from  the  communication  with 
analogous  and  more  superficial  formations  only  by  the  method  of 
preparation,  \\z,  cutting  into  thin  lamellae. 

Fig.  4t. 


On  the  surface  of  the  carious  portion  of  dentine  we  see  irregular 
cavities  filled  with  the  same  granular  mass  that  is  present  in  the  fis- 
sures, consisting  evidently  of  debris  of  the  former  tissue,  together, 
perhaps,  with  micrococci,  and  very  often  fine  thread-hke  leptothrix. 
The  more  rapidly  the  destruction  of  the  dentine  has  advanced, 
the  more  irregular  islands  of  dentine  are  left  on  the  surface.  (See 
Fig.  41,  b,  b.)  In  our  figure  the  decay  evidently  has  proceeded 
rapidly  ;  hence  the  remnants  of  the  former  dentine,  recognizable  by 
the  presence  of  the  canaliculi,  are  very  small  and  irregular  on  the 
outer  periphery  of  the  dentine. 

The  outermost  portion  of  the  decayed  part  is,  as  a  rule,  brittle,  and 
crumbles  away  in  chromic  acid  specimens.  Where  it  is  left  it  shows 
a  swarm  of  leptothrix  and  micrococci,  without  any  distinctly  recog- 


8o  DENTAL   PATHOLOGY   AND   PRACTICE. 

nizable  remnants  of  the  former  tissue.  On  the  boundary  of  the 
carious  portion  we  meet  with  a  yellow  discoloration  of  the  dentine 
before  mentioned,  which  is  evidently  produced  by  a  chemical  agent, 
which  produces  an  irritation  of  the  contents  of  the  canaliculi,  causing 
it  to  increase  in  bulk  and  become  liquefied,  thus  breaking  down  their 
walls  of  lime-salts,  which  eventually  are  dissolved  by  acids  and 
washed  away.  In  live  teeth  the  yellow  discoloration  usually  takes 
place  in  the  shape  of  longitudinal  strings  of  different  diameters,  run- 
ning mainly  parallel  with  the  longitudinal  direction  of  the  dentinal 
canaliculi.  Nay,  we  often  see  single  yellow  strings  running  from  the 
bottom  of  a  carious  cavity  in  the  enamel  through  the  entire  depth 
of  the  dentine  to  the  pulp-chambers.  (See  Fig.  41,  c,  c.)  The  best 
method  for  demonstrating  these  strings  is  doubtless  the  staining  of 
chromic  acid  specimens  in  an  ammoniacal  solution  of  carmine.  While 
the  unchanged  dentine  readily  takes  up  the  carmine,  the  strings,  the 
deep  yellow  color  of  which  is  undoubtedly  due  to  the  action  of  the 
chromic  acid,  remain  unstained. 

With  a  power  of  about  five  hundred  diameters,  we  recognize  under 
the  microscope,  in  longitudinal  section  of  the  dentine,  that  sometimes 
the  yellow  discoloration  has  taken  place  only  within  the  limits  of  a 
few  dentinal  canaliculi,  while  at  other  times  quite  a  number  of  these 
have  undergone  discoloration.  Still  sharper  defined  is  the  yellow 
discoloration  on  transverse  sections.  Here  we  see  that  the  canaliculi 
and  their  immediate  neighborhood  mainly  have  taken  up  the  yellow 
color  in  the  shape  of  sharply-circumscribed  dots,  which  are  larger  the 
nearer  they  approach  to  the  periphery  of  the  decayed  part.  The 
basis-substance  between  these  yellow  spots  has  taken  up  more  or 
less  carmine.  Let  us  examine  such  a  cross-section  with  a  magnifying 
power  of  one  thousand  diameters  under  the  microscope. 

At  a  certain  distance  from  the  decay  the  canaliculi  look  unchanged, 
and  each  contains  the  central  transverse  section  of  the  dentinal  fiber, 
with  its  delicate  radiated  offshoots.  (See  Fig.  42,  «.)  Nearer  to  the 
decay  we  meet  with  moderately- enlarged  canaliculi,  the  center  of 
which  is  occupied  by  a  cluster  of  protoplasm,  the  granules  and  threads 
of  which  have  readily  taken  up  the  carmine.  (See  Fig.  42,  b,  b.)  One 
step  farther  we  find  the  canaliculi  considerably  enlarged,  to  double 
or  treble  their  original  size,  and  they  are  filled  with  yellow  protoplasm, 
plainly  exhibiting  the  net-like  arrangement  of  the  living  matter.  (See 
Fig.  42,  c,  c.)  The  most  peripheral  granules  send  delicate  conical 
offshoots  through  the  surrounding  light  space  toward  the  unchanged 
basis-substance.  In  some  of  the  enlarged  canaliculi  accumulations  of 
living  matter  are  seen  of  the  same  shape  as  nuclei  ;  sometimes  two 
or  more  such  nuclei  may  be  seen  surrounded  by  a  varying  amount  of 
protoplasm.     (See  Fig.  42,  d,  d.)    Still  nearer  to  the  decay  the  canali- 


PLATE   B. 


CARIOUS   DENTINE,    LONGITUDINAL  SECTION. 


«,  Normal  dentine  ;  b,  b,  b,  b,  dentine  reduced  to  its  medullary  con- 
dition through  inflammatory  reaction  ;  c,  zone  of  inflamed  dentine, 
showing  a  generally  disorganized  condition,  and  greatly  enlarged 
canaliculi ;  d,  dentine  breaking  down  after  decalcification,  death  and 
putrefaction. 

X  600. 


PLATE   C. 


CARIOUS  DENTINE,    CROSS  SECTION. 

a,  Normal  dentine  ;  b,  b,  swollen  canaliculi  from  inflammation. 


CARIES    OF    HUMAN    TEETH. 


8r 


culi  are  enlarged  to  ten  or  fifteen  times  their  original  diameter,  and  the 
cavities  thus  produced  are  all  filled  with  a  partly-nucleated  protoplasm. 
(See  Fig.  42,  <?,  e.')  Between  the  roundish  cavities  we  meet  with  longi- 
tudinal cavities,  arising  firom  the  confluence  of  several  cavities  in  one 
main  direction.  (See  Fig.  42,/.)  The  cavities  continue  increasing  in 
size,  and  form  large  spaces,  with  rounded,  bay-like  boundaries,  between 
which  only  scanty  traces  of  unchanged  basis-substance  are  left.  (See 
Fig.  42,  g,g.)  Lastly,  the  basis-substance  has  entirely  disappeared, 
and  only  protoplasm  is  visible  in  its  place,  in  the  shape  either  of  multi- 

FiG.  42. 


nuclear  layers  or  of  irregular  so-called  medullary  elements  with  rather 
faint  marks  of  division.  (See  Fig.  42,  k,  h.)  Nearest  to  the  periphery 
the  protoplasm  does  not  exhibit  any  form  elements,  but  looks  like  a 
disintegrated  granular  mass,  probably  intermixed  with  or  replaced 
by  micrococci.  I  say  probably,  inasmuch  as  all  good  histologists 
agree,  nowadays,  that  the  diagnosis  of  micrococci  is  possible  only 
when  they  are  clustered  together,  which  is  not  always  demonstrable 
even  in  the  thoroughly-decayed  mass. 

We  have  a  series  of  changes  of  the  dentine  fibers,  and  the  surround- 

7 


82 


DENTAL  PATHOLOGY  AND  PRACTICE, 


ing  basis-substance  of  the  dentine  before  us,  which  I  have  not  the  least 
doubt  is  the  normal  procedure  of  the  transformation  of  dentine  by  the 
carious  process. 

Fig.  43  is  an  oblique  section,  and  illustrates  exactly  the  same 
changes  from  a  tooth  attacked  by  a  less  acute  caries,  perhaps  owing 
to  its  greater  solidity  or  more  perfect  calcification.  Here  a  relatively 
small  number  of  dentinal  canaliculi  are  enlarged  and  filled  with  proto- 
plasm. (See  Fig.  43,  a,  a.)  The  center  of  the  protoplasmic  bodies  is 
occupied  by  one  or  two  nuclei,  which  look  as  if  they  originated  from 
the  former  dentinal  fiber.     On  the  periphery  of  the  dentine  there 

Fig.  43. 


are  regular  nests  filled  with  protoplasmic  lormations  of  the  above 
description,  partly  broken  down  into  medullary  elements.  (See  Fig. 
43,  b,  b.)  On  other  parts,  on  the  contrary,  the  transformation  of  the 
basis-substance  into  protoplasm  has  even  preceded  the  changes  of  the 
dentinal  fibers.  (See  Fig.  43,  r.)  The  canaliculi  are  not  noticeably 
enlarged  ;  the  dentinal  fibers  are  either  unchanged  or  slightly  swollen, 
and  more  granular  than  in  the  normal  condition  ;  while  outside  these 
we  have  a  thoroughly  decalcified  and  liquefied  basis-substance,  which 
means  a  reappearance  of  the  net-work  of  the  living  matter  before  the 
stage  of  disintegration. 


caries  of  human  teeth.  83 

Caries  of  Cement. 

So  long  as  the  gums  are  in  their  normal  condition  and  position, 
caries  does  not  begin  in  the  cement  ;  but  if  the  gums  have  receded 
from  any  cause,  thus  exposing  the  cement  which  covers  the  necks 
of  the  teeth,  it  may  then  begin  to  decay.  I  have  never  had  an  op- 
portunity of  examining  primary  caries  of  cement  under  the  micro- 
scope, but  of  caries  of  this  tissue  advanced  from  within,  viz,  from  de- 
cayed dentine,  I  have  several  specimens.  The  microscope  reveals  in 
these  specimens  a  more  or  less  advanced  decay,  which  in  its  essential 
features  is  quite  analogous  to  caries  of  the  dentine  when  in  a  live 


condition  ;  in  other  words,  it  is  an  inflammatory  process.  On  the 
boundary  of  the  caries  we  see,  besides  unchanged  cement-corpuscles 
(see  Fig.  44,  a,  a),  those  which  have  been  enlarged  and  transformed 
into  medullary  or  inflammatory  elements.  (See  Fig.  44,  b,  b. )  Nay, 
I  have  observed  that  the  lacunae  holding  the  protoplasmic  body 
were  partly  unchanged,  while  a  portion  participated  in  the  inflamma- 
tory process.     (See  Fig.  44,  <:,  c.) 

The  enlargement  of  the  cement-corpuscles  is  evidently  not  due  to 
a  direct  swelling  of  the  protoplasm  itself,  but  to  a  liquefaction  of  the 
surrounding  basis-substance,  in  which  the  protoplasmic  condition, 
and  with  this  also  the  medullary  elements  which  ha^•e  participated  in 
the  formation  of  the  basis-substance,  reappears.     The  inflamed  por- 


84  DENTAL    PATHOLOGY   AND    PRACTICE. 

tions  of  the  cement  look  granular  with  lower  powers  of  the  micro- 
scope, but  high  powers  reveal  the  net-like  structure  of  the  living 
matter,  and  the  formation  of  irregular  polyhedral  elements  which  are 
separated  from  one  another  by  a  light,  narrow  seam,  this  being  tra- 
versed by  extremely  delicate  uniting  threads. 

The  history  of  development  of  bone  demonstrates  that  this  tissue 
originates  from  medullary  elements,  the  so-called  osteoblasts,  which 
remain  partly  unchanged,  and  as  such  form  the  bone-corpuscles,  while 
their  greater  part  is  transformed  into  basis-substance  (Waldeyer). 
The  history  of  the  development  of  the  cement  has  not  as  yet  been 
studied,  but  we  have  good  reasons  for  assuming  that  it  develops  in  a 
way  identical  with  that  of  bone,  as  both  tissues  are  identical  in  their 
structure,  and  exhibit  identical  results  when  inflamed. 

Dr.  C.  Heitzmann  has  drawn  attention  to  the  fact  that  the  proto- 
plasm of  the  medullary  elements,  when  transformed  into  glue-giving 
basis-substance,  does  not  altogether  perish.  It  is  only  the  fluid,  non- 
living part  of  the  protoplasm  which,  by  chemical  changes,  is  trans- 
formed into  glue  ;  the  living  part  of  the  protoplasm,  on  the  contrary, 
remains  unchanged,  and  is  simply  concealed  by  the  refracting  power 
of  the  glue-giving  basis-substance.  That  this  view  is  correct,  the  in- 
vestigator referred  to  has  proven  by  the  appearances  in  inflamed  bone, 
and  I  can  fully  corroborate  his  views  from  my  observations  on  inflamed 
cement. 

Virchow's  view  that  the  bone-corpuscles  swell  and  divide  into 
inflammatory  elements  by  being  converted  into  proliferating  mother 
cells,  is  in  my  opinion  wrong.  No  proliferation  is  demonstrable  in 
the  earliest  stages  of  inflammation  of  the  cement.  Nothing  but  a 
liquefaction,  and  thereafter  a  decalcification,  of  the  glue-giving  basis- 
substance  takes  place  in  order  to  bring  to  view  the  very  same  medul- 
lary elements  which  had  previously  shared  in  the  formation  of  the 
cement.  The  inflammatory  reaction  in  the  cement-corpuscle  itself 
may  be  so  slight  that  (as  mentioned  above)  a  part  of  this  protoplasm 
may  look  almost  unchanged,  while  another  part  toward  the  liquefied 
basis-substance  gives  an  appearance  identical  with  that  surrounding  it. 
The  result  of  this  process  is  a  transformation  of  the  tissue  of  the 
cement  into  medullary  or  inflammatory  elements.  (See  Fig.  44,  d,  </.) 
These  remain  in  connection  with  one  another  by  delicate  threads  of 
living  matter,  but  at  last  become  disintegrated,  and  give,  together 
with  micrococci  and  leptothrix  threads,  a  decayed  mass,  just  as  well 
as  enamel  and  dentine. 

Results. — After  having  examined  microscopically  teeth  attacked  by 
the  carious  process  from  the  mouths  of  over  one  hundred  different 
persons,  I  can  sum  up  the  results  of  my  researches  in  the  following 
aphorisms. 


CARIES    OF    HUMAN   TEETH.  85 

I.  In  enamel,  caries  in  its  earliest  stage  is  a  chemical  process.  After 
the  lime-salts  are  dislodged,  and  the  basis-substance  liquefied,  the 
protoplasm  reappears,  and  breaks  apart  into  small,  irregularly-shaped 
so-called  medullary  or  embryonal  bodies. 

II.  Caries  of  dentine  consists  in  an  irritation  and  consequent  swelling 
of  the  contents  of  the  canaliculi,  a  dislodgment  of  the  lime-salts,  and  in 
turn  a  dissolution  of  the  glue-giving  basis-substance  around  the  canali- 
culi as  well  as  between  them.  The  living  matter  contained  in  the 
canaliculi  is  transformed  into  nucleated  protoplasmic  bodies,  which, 
with  protoplasmic  bodies  originating  from  the  living  matter  in  the 
basis-substance,  form  the  so-called  indifferent  or  inflammatory  tissue. 

III.  Cement,  if  attacked  by  caries,  exhibits  first  all  the  phenomena 
known  to  be  present  in  the  early  stages  of  inflammation  of  bone.  The 
protoplasmic  cement-corpuscles,  as  well  as  the  basis-substance  after  its 
disorganization  and  liquefaction,  produce  indifferent  or  inflammatory 
elements. 

IV.  The  indifferent  elements  originating  through  the  carious  pro- 
cess from  enamel,  dentine,  and  cement  do  not  proceed  in  new  forma- 
tion of  living  matter,  but  become  disintegrated  and  transformed  into 
a  mass  crowded  with  micrococci  and  leptothrix. 

V.  Caries  of  a  living  tooth,  therefore,  is  an  inflammatory  process, 
which,  beginning  as  a  chemical  process,  in  turn  reduces  the  tissues  of 
the  tooth  into  embryonic  or  medullary  elements,  evidently  the  same  as 
during  the  development  of  the  tooth  shared  in  its  formation  ;  and  the 
development  and  intensity  of  the  caries  are  in  direct  proportion  to  the 
amount  of  living  matter  which  the  enamel,  dentine,  and  cement  con- 
tain, as  compared  with  other  tissues. 

VI.  The  medullary  elements,  owing  to  want  of  nutrition  and  to 
continuous  irritation,  become  necrosed,  and  the  seat  of  a  lively  new 
growth  of  organisms  common  to  all  decomposing  organic  material. 

VII.  Micrococci  and  leptothrix  by  no  means  produce  caries  ;  they 
do  not  penetrate  the  cavities  in  the  basis-substance  of  the  tissues  of 
the  tooth,  but  appear  only  as  secondary  formations,  owing  to  the 
decay  of  the  medullary  elements. 

VIII.  In  dead  and  artificial  teeth  caries  is  a  chemical  process, 
assisted  only  by  the  decomposition  of  the  glue-giving  basis-substance 
of  dentine  and  cement. 

History. 

John  Hunter,  "Diseases  of  the  Teeth,"  etc.,  1778,  says,  "The 
most  common  disease  to  which  the  teeth  are  exposed  is  such  a  decay 
as  would  appear  to  deserve  the  name  of  mortification.  But  there  is 
something  more,  for  the  simple  death  of  the  part  would  produce  but 
little  effect,  as  we  find  that  teeth  are  not  subject  to  putrefaction  after 


86  DENTAL  PATHOLOGY  AND  PRACTICE. 

death,  and  therefore  I  am  apt  to  suspect  that  durhig  hfe  there  is  some 
operation  going  on  which  produces  a  change  in  the  diseased  part." 

Joseph  Fox,  "The  History  and  Treatment  of  the  Diseases  of  the 
Teeth  and  Gums,"  1806,  says,  "The  diseases  to  which  the  teeth  are 
subject  are  similar  to  those  which  affect  bones  in  general,  and  in  like 
manner  they  have  their  origin  in  inflammation.  The  teeth  differ  only 
from  bones  in  not  possessing  sufficient  living  power  to  effect  the  pro- 
cess of  exfoliation." 

Thomas  Bell,  "Anatomy,  Physiology,  and  Diseases  of  Teeth,"  1831, 
under  the  heading  of  "  Gangrene  of  the  Teeth,  commonly  called 
Caries,"  says,  "The  most  common  disease  to  which  the  teeth  are 
liable  is  that  which  has  hitherto  been  universally  known  under  the 
name  of  caries^ — a  name  which,  although  authorized  both  by  English 
and  Continental  writers,  is  in  this  instance  totally  misapplied.  It  is, 
in  fact,  calculated  essentially  to  mislead,  as  the  disease  has  not  the 
slightest  analogy  to  true  caries  of  bone.  The  perpetuation  of  so 
obvious  an  error  as  this  is  surely  more  than  the  most  fastidious  oppo- 
nent of  innovation  could  require.  I  propose,  therefore,  to  substitute 
for  it  the  term  gangrene  of  the  teeth,  a  word  which  expresses  the  real 
nature  of  the  disease.  It  may  be  defined  as  mortification  of  any  part 
of  a  tooth,  producing  gradual  decomposition  of  its  substance." 

Farther  on  he  says,  "  Still,  however,  the  true  proximate  cause  of 
dental  gangrene  is  inflammation.  And  the  following  appears  to  me 
to  be  the  manner  in  which  it  takes  place.  When,  from  cold  or  from 
any  other  cause,  a  tooth  becomes  inflamed,  the  part  which  suffers  the 
most  severely  is  unable,  from  its  possessing  comparatively  but  a  small 
degree  of  vital  power,  to  recover  from  the  effects  of  inflammation,  and 
mortification  of  that  part  is  the  consequence.  That  the  bony  struc- 
ture of  the  teeth  is  liable  to  inflammation,  appears  not  only  from  the 
identity  of  the  symptoms  which  take  place  in  them,  when  exposed  to 
causes  likely  to  produce  it,  with  those  which  are  observed  in  the  other 
bones  when  inflamed,  but  more  conclusively  still  from  the  facts  already 
mentioned,  that  teeth  are  occasionally  found  in  which  distinct  patches, 
injected  with  the  red  particles  of  blood,  have  been  produced  by  this 
cause  after  the  continuance  of  severe  pain." 

Dr.  E.  Magitot,  "  Treatise  on  Dental  Caries"  (English  translation 
by  Dr.  T.  H.  Chandler,  1878),  in  his  general  conclusions  says, — 

"  I.  Dental  caries  is  a  purely  chemical  alteration  of  the  enamel  and 
ivory  of  the  teeth.  Dental  caries  is  one.  The  varieties  of  form  and 
color  depend  upon  simple  secondary  variations  in  the  nature  of  the 
altering  cause,  the  progress,  and  the  duration  of  the  malady. 

' '  Lesions  of  the  enamel  consist,  after  the  removal  of  the  cuticle,  in 
a  purely  passive  chemical  disorganization  of  the  prisms  composing 
its  tissue. 


CARIES    OF    HUMAN    TEETH.  87 

' '  Lesions  of  the  ivory,  consisting  likewise  in  a  chemical  decomposi- 
tion of  its  elements,  may  sometimes,  though  rarely,  remain  passive  ; 
but  most  frequently  they  determine  in  the  tissue  phenomena  of  re- 
action that  manifest  themselves  by  the  appearance  of  a  cone  or  white 
zone  formed  by  a  mass  of  canalicules  obliterated  in  consequence  of  a 
formation  of  secondary  dentine. 

' '  The  tooth  attacked  by  caries  does  not  remain  passive  and  inert, 
but  may  in  some  measure  undertake  to  resist  its  action  by  the  phe- 
nomena of  condensing  dentification  of  the  ivory. 

' '  The  agent  of  dental  caries  is  the  saliva,  become  the  medium  of  acid 
fermentation,  or  the  vehicle  of  foreign  substances  susceptible  of  alter- 
ing directly  the  tissues  of  the  ivory  and  the  enamel.  Caries  can  be 
caused  artificially  by  imitating  the  conditions  of  alteration  that  the 
mouth  itself  may  present.  It  then  offers  the  same  characteristics  as 
the  morbid  caries,  with  the  exception  of  the  phenomena  of  the  organic 
resistance. 

"  The  intimate  mechanism  of  the  production  of  caries  is  a  simple 
solution  of  the  mineral  and  calcareous  salts  which  enter  into  the  con- 
stitution of  the  enamel  and  of  the  ivory,  by  the  agent  of  new  forma- 
tion." 

Drs.  Leber  and  Rottenstein,  "  Dental  Caries  and  its  Causes,"  1873, 
say,  "We  have  already  several  times  remarked  that  the  action  of 
acids  alone  does  not  account  for  all  the  phenomena  which  appear  in 
caries  of  the  teeth.  It  is  true  that  acids,  even  very  much  diluted,  can 
attack  the  dental  tissue  ;  but  we  find  in  their  mode  of  action  differ- 
ences which  distinguish  them  from  the  phenomena  and  from  the  pro- 
gress of  dental  caries.  The  acids  attack  first  the  enamel  and  rapidly 
change  it  to  a  chalky  mass  ;  later  on  their  action  is  felt  in  a  marked 
manner  upon  the  dentine,  which  becomes  more  transparent,  and,  in 
fine,  as  if  cartilaginous,  by  the  very  slow  but  progressive  loss  of  its 
calcareous  salts. 

' '  Caries,  on  the  contrary,  proceeds  slowly  in  the  enamel  ;  it  is 
much  swifter  in  the  dentine,  where  it  proceeds  promptly  along  the 
canaliculi.  This  difference  of  progress  must  be  attributed  to  the 
participation  of  the  fungi  in  the  work  of  the  caries.  The  elements  of 
the  fungus  gUde  easily  into  the  interior  of  the  canaliculi,  which  they 
dilate,  and  thus  favor  the  passage  of  the  acids  into  the  deeper  parts  ; 
these  same  elements  cannot  penetrate  a  compact  enamel,  or  at  least 
they  enter  more  slowly,  and  only  when  the  elements  which  form  it 
have  been  greatly  changed  by  the  action  of  acids.  .  .  .  For 
them  (the  leptothrix)  to  be  able  to  penetrate  thus,  it  is  necessary  that 
the  teeth  be  in  a  suitable  condition  ;  the  enamel  and  the  dentine  must 
have  lost  their  density  by  the  action  of  acids.  It  seems  that  the  fungi 
are  not  able  to  penetrate  an  enamel  of  normal  consistence.     The 


88  DENTAL   PATHOLOGY    AND    PRACTICE. 

dentine  itself,  in  its  normal  condition  of  density,  offers  great  difficulties 
to  their  entrance,  and  we  are  not  yet  sure  that  the  leptothrix  could 
triumph  over  this  resistance.  .  .  .  We  cannot  decide  at  present 
if  the  leptothrix  is  able  to  penetrate  sound  dentine  when  from  any 
abnormal  circumstance  it  happens  to  be  denuded  ;  but  if  the  enamel 
or  the  dentine  are  become  less  resistant  at  any  point  through  the 
action  of  acids,  or  if  at  the  surface  of  the  dentine  a  loss  of  substance 
has  occurred,  then  the  elements  of  the  fungus  can  pass  into  the 
interior  of  the  dental  tissues  and  produce  by  their  extension,  espe- 
cially in  the  dentine,  effects  of  softening  and  destruction  much  more 
rapid  than  the  action  of  acids  alone  is  able  to  accomplish." 

Carl  Wedl,  "  Pathology  of  the  Teeth,"  1872,  says,  "  It  was  quite 
natural  to  transfer  to  the  teeth  the  signification  implied  in  the  expres- 
sion '  caries  of  bone  ;'  indeed,  the  fundamental  phenomena,  namely, 
the  destruction  of  the  hard  tissues,  offered  a  striking  analogy.  In 
their  development,  however,  the  two  processes  by  no  means  present 
such  an  identity.  Caries  of  bone,  as  is  well  known,  is  an  inflamma- 
tory process  (osteitis)  which  originates  in  the  soft  parts  of  the  bone 
and  erodes  its  hard  tissue.  This  is  not  the  case  with  the  carious 
process  in  the  teeth,  which  commences  in  the  hard  tissues  and 
spreads  to  the  vascularized  and  nervous  dental  pulp.  Upon  close 
investigation  the  latter  process  is  found  to  be  so  entirely  distinct  from 
the  former  that  the  attempt  has  repeatedly  been  made  to  expunge 
altogether  from  the  nomenclature  of  diseases  of  the  teeth  the  expres- 
sion '  caries  of  the  teeth.' 

' '  Notwithstanding  the  fact  that  our  knowledge  is  advancing, 
unquestionably,  with  the  continual  addition  to  the  auxiliary  means  at 
our  command  for  carrying  on  the  work,  it  must,  however,  be 
acknowledged  that  a  theory  with  regard  to  caries  with  a  thoroughly 
scientific  basis  in  all  its  details  is  still  wanting. 

"  In  sections  made  in  a  dii-ection  transverse  to  the  axes  of  the  radi- 
ating dentinal  canals,  a  greater  or  less  number  of  canals  are  met  with 
whose  limiting  walls  (the  so-called  dentinal  sheaths)  describe  unusu- 
ally large  circles,  and  whose  cavities  are  replete  with  a  mass  which 
has  in  some  places  a  homogeneous,  in  others  a  molecular  appear- 
ance, and  forms  convex  projections  beyond  the  surface  of  the  section. 
The  transverse  diameters  of  the  widened  and  filled  canals  vary,  some 
being  at  least  three  times  as  large  as  others.  The  intertubular  tissue 
presents  a  molecular  cloudiness,  and  is  beset  with  grains  having  the 
appearance  of  fat.  In  sections  made  parallel  to  the  long  axes  of  the 
canals  they  are  quite  clearly  seen  to  be  unequally  filled  by  the  foreign 
mass,  since  they  present  manifold  varicosities  and  constrictions, 
which  also  explain  the  variations  in  the  diameters  of  the  widened 
canals.     ... 


CARIES   OF    HUMAN   TEETH.  8g 

"  Since  we  know  that  an  interchange  of  material  takes  place  in  the 
dentine  and  cement  during  life,  as  is  proved  by  the  occurrence  of 
atrophies,  hypertrophies,  and  new  formations,  and  that  the  dentine 
possesses  a  degree  of  sensibility,  we  cannot  reject  absolutely  the  idea 
of  a  reaction  on  the  part  of  both  hard  tissues  against  the  effects  of 
external  agents. 

' '  Some  authors  seem  to  have  had  an  intimation  of  this  idea,  since 
they  were  inclined  to  consider  the  textural  changes  in  carious  dentine 
as  vital  processes.  There  can  be  no  doubt  that  the  sensibility,  some- 
times increasing  to  actual  pain,  of  the  dentine,  when  deprived  of  its 
protecting  covering,  is  a  vital  action,  and  that  this  becomes  dimin- 
ished when  the  most  sensitive,  the  peripheral  portion,  is  destroyed  by 
an  external  agent.  These  facts,  however,  are  by  no  means  sufficient 
to  enable  us  to  draw  a  conclusion  in  favor  of  the  reactionary  power 
of  dentine  in  parts  which  are  attacked  by  caries. 

' '  In  consequence  of  the  decomposition  of  the  secretions,  acids  are 
formed  which  extract  the  calcareous  salts  from  the  hard  tissue,  and 
give  rise  to  a  disintegration  of  the  affected  portions  of  the  latter,  in 
which  no  inflammatory  reaction  occurs." 

Tomes,  "System  of  Dental  Surgery,"  1873,  says,  "Although 
dental  caries  has  been  investigated  and  described  by  all  who  have 
written  upon  the  subject  of  dental  surgery,  from  the  earliest  period 
when  disorders  of  the  teeth  first  attracted  attention  down  to  the 
present  time,  yet  it  can  scarcely  be  said  that  the  nature  of  the  disease 
is  perfectly  understood,  for  even  now  two  hypotheses  prevail.  In 
one  the  disease  is  assumed  to  be  no  disease  whatever,  but  merely  the 
result  of  chemical  solution  of  the  dental  tissues,  and  therefore 
dependent  both  in  its  origin  and  its  progress  on  the  uncontrolled 
action  of  physical  and  chemical  laws.  According  to  the  other 
hypothesis,  the  fact  that  teeth  are  part  of  a  living  organism,  if  not 
essential  to  the  origin  of  the  mischief,  at  all  events  profoundly  modi- 
fies its  progress.  Much  has  been  written  in  favor  of  each  of  these 
views,  and  yet  the  subject  cannot  by  any  means  be  held  to  be  settled." 

In  the  appendix  to  this  work  we  find  the  following  "  conclusions," 
viz  : 

That  caries  is  an  effect  of  external  causes  in  which  so-called 
"  vital"  forces  play  no  part.  That  it  is  due  to  the  solvent  action  of 
acids  which  have  been  generated  by  fermentation  going  on  in  the 
mouth,  the  buccal  mucus  probably  having  no  small  share  in  the  mat- 
ter ;  and  when  once  the  disintegrating  pi'ocess  is  established  at  some 
congenitally  defective  point,  the  accumulations  of  food  and  secretions 
in  the  cavity  will  intensify  the  mischief  by  furnishing  fresh  supplies 
of  acids. 


90  DENTAL  PATHOLOGY  AND  PRACTICE. 

CHAPTER   VIII. 

CHILDREN'S   TEETH   AND   THEIR   TREATMENT. 

The  term  "children's  teeth,"  as  here  used,  refers  more  particu- 
larly to  the  temporary  or  deciduous  set,  which  are  twenty  in  number, 
and  which  usually  come  into  the  mouth  as  follows,  viz  : 

Lower  central  incisors  from  the  5th  to  the  7th  month. 

Upper  central  incisors  from  the  6th  to  the  gth  month. 

Lower  lateral  incisors  from  the  7th  to  the  loth  month. 

Upper  lateral  incisors  from  the  7th  to  the  nth  month. 

Lower  first  molars  from  the  nth  to  the  17th  month. 

Upper  first  molars  from  the  12th  to  the  i8th  month. 

Lower  cuspids  from  the  13th  to  the  20th  month. 

Upper  cuspids  from  the  14th  to  the  22d  month. 

Lower  second  molars  from  the  i8th  to  the  28th  month. 

Upper  second  molars  from  the  20th  to  the  30th  month. 

Thus  it  will  be  seen  that  at  two  and  one-half  years  of  age  a  child 
has  its  full  complement  of  temporary  teeth  in  position.  At  this  time 
it  should  be  taken  to  the  family  dentist  and  have  its  teeth  thoroughly 
examined  for  any  faulty  structural  development.  If  any  defects  be 
present,  they  will  usually  be  found  in  the  crowns  of  the  teeth  which 
have  come  into  the  mouth  last, — the  second  molars, — in  the  depres- 
sions of  which  it  often  occurs  that  perfect  formation  of  the  enamel  is 
lacking,  leaving  very  minute  openings  through  the  enamel  to  the 
dentine. 

The  examination  is  made  with  the  finest  exploring-needle.  Should 
it  be  readily  introduced  at  any  point  so  that  only  slight  force  is  re- 
quired to  remove  it,  the  opening  should  be  enlarged,  properly 
shaped,  and  a  plastic  filling  (amalgam)  introduced.  This  is  done  at 
this  early  period,  first,  to  save  the  tooth  from  caries  ;  second,  that  the 
operation  may  be  done  before  the  tooth  has  been  destroyed  suffi- 
ciently to  render  the  operation  painful ;  and,  third,  to  impress  upon 
the  child  the  fact  that  operations  upon  the  teeth  may  be  done  without 
pain.  When  this  has  been  accomplished,  a  start  in  the  right  direc- 
tion has  been  made  with  the  child,  which  it  will  always  remember 
with  more  or  less  pleasure.  With  proper  directions  as  to  the  manner 
of  keeping  the  teeth  clean,  the  little  patient  is  dismissed,  with 
instructions  to  return  every  six  months. 

As  a  rule,  all  fillings  in  children's  teeth  should  be  made  with  plastics, 
as  they  are  put  in  more  readily,  with  less  labor,  and  consequently 
with  less  fatigue  to  the  child. 

In  this  connection  I  cannot  impress  the  fact  too  strongly  upon  the 


CHILDREN  S   TEETH    AND    THEIR   TREATMENT.  9I 

young  practitioner,  that  a  kind  and  extremely  gentle  manner  of  con- 
ducting all  operations  upon  the  teeth  is  always  to  be  observed,  espe- 
cially with  children. 

Should  a  pulp  be  found  exposed  in  a  child's  tooth,  great  care 
should  be  exercised  to  avoid  even  touching  it.  The  cavity  should 
first  be  prepared  in  all  directions,  except  toward  the  exposed  pulp  ; 
then,  with  a  broad-bladed,  round-pointed  excavator,  the  loose  or 
decalcified  tooth-structure  may  be  removed  over  and  around  the  ex- 
posed point,  washing  out  frequently  with  warm  water.  When  the 
lateral  walls  are  sufficiently  cleansed  to  be  preserved  from  further 
decay  by  the  filling,  a  bit  of  cotton  the  size  of  a  pin's  head  is  satu- 
rated with  wood  creasote,  placed  upon  the  exposed  pulp,  and  a 
saucer-shaped  cap  of  metal,  with  its  concave  surface  toward  the 
pulp,  is  placed  over  it.  Over  this  a  filling  is  introduced.  I  find  this 
mode  of  procedure  much  more  satisfactory,  and  the  results  more 
comfortable  and  lasting  to  the  little  patient,  than  capping  with 
cement. 

Should  the  exposure  of  the  pulp  be  one  of  long  standing,  and 
the  child  have  suffered  more  or  less  pain  from  it,  an  application 
of  creasote  is  made  upon  a  bit  of  cotton,  and  covered  temporarily 
with  gutta-percha  and  wax  (a  mixture  of  equal  parts  of  pink  gutta- 
percha and  wax  ;  the  mixture  is  made  in  a  vessel  standing  in  a  hot- 
water  bath).  This  is  allowed  to  remain  a  day  or  two,  when  it  is 
removed.  If  the  pulp  is  still  alive,  and  the  child  has  experienced  no 
pain  since  the  last  visit,  the  operation  is  proceeded  with  as  in  the  first 
instance.  Should  the  pulp  be  dead,  which  is  very  often  the  case, 
after  such  application,  and  it  is  desirable  to  retain  the  tooth  in  the 
mouth  for  a  length  of  time  for  any  reason,  the  case  is  treated  as  a 
pulpless  temporary  tooth,  as  follows  : 

The  pulp-chamber  is  well  opened,  and,  with  the  canals,  is  as  thor- 
oughly cleansed  as  possible,  and  washed  out  with  a  solution  of 
Ytr^inr  bichlorid.  Then  a  small  hole  is  drilled  through  to  the  pulp- 
chamber  from  a  point  on  the  neck  of  the  tooth  under  the  margin  of 
the  gum.  A  cap  of  metal  is  then  placed  in  the  cavity,  leaving  the 
pulp-chamber  open,  so  that  free  drainage  may  take  place  from  the 
canal  or  canals  cut  through  the  drill-hole.  A  suitable  filling  is  then 
put  into  the  tooth.  This  treatment  of  pulpless  temporary  teeth  I 
adopted  many  years  ago  as  the  only  one  which  would  keep  such 
teeth  comfortable  and  useful  in  a  child's  mouth.  It  usually  prevents 
the  formation  of  an  abscess,  which,  if  the  drainage  be  not  given,  is 
very  sure  to  follow  the  filling  of  such  teeth.  It  is  altogether  unsafe 
to  fill  the  canals  in  these  cases,  as  a  portion  of  the  root  has  probably 
been  absorbed  away  previous  to  the  death  of  the  pulp,  leaving  at  the 
end  of  the  root  a  broad  opening  through  which  any  filling-material 


92  DENTAL  PATHOLOGY  AND  PRACTICE. 

is  likely  to  be  forced.  Again,  should  exit  for  serum  be  cut  off  by 
filling,  an  abscess  is  very  sure  to  be  the  result.  This  serum  is  the 
inevitable  result  of  irritation  of  the  soft  parts  immediately  in  contact 
with  the  partially  absorbed  rough  end  of  the  root,  a  constant  exuda- 
tion taking  place  into  the  pulp-canals,  which  the  drainage-tube  carries 
off  with  no  pain  or  trouble,  until  it  is  time  for  the  tooth  to  be  re- 
moved. If  the  pulp  has  died  and  undergone  putrefaction,  and  an 
abscess  has  formed,  the  treatment  is  the  same,  except  that  a  solution 
of  zinc  chlorid  (grains  x  to  water  gj)  is  forced  through  the  abscess,  if 
it  be  practicable.  In  many  instances  it  is  not,  as  the  child  will  often 
protest  so  seriously  against  any  material  in  the  mouth  that  has  the 
slightest  unpleasant  taste  that  it  is  quite  impossible.  This,  however,  is 
often  overcome  by  placing  a  napkin  over  the  tongue,  folded  thick 
enough  to  absorb  the  solution  as  it  comes  from  the  tooth  or  gum. 

The  object  in  all  this  trouble  to  keep  the  temporary  teeth  in  the 
mouth,  notwithstanding  their  pulpless  and  abscessed  condition,  is 
primarily  to  keep  the  permanent  teeth  from  coming  in  too  early,  and 
thus  allowing  nature,  which  is  always  kind  in  such  matters,  to  more 
fully  develop  them  and  more  perfectly  arrange  them  regularly  in  the 
jaws  before  they  pierce  the  gum.  The  result  usually  is  that  the  jaw 
grows  to  its  normal  size  and  the  teeth  come  in  regularly,  instead  of 
the  jaw  being  narrow  and  the  teeth  crowded  out  of  their  proper 
positions. 

It  is  interesting  to  watch  the  changes  that  take  place  in  the  growing 
of  a  child's  jaws.  In  front,  at  the  age  of  about  four  years,  it  will  be 
noticed  that  the  teeth  have  begun  to  separate  slightly  ;  these  separa- 
tions increase  day  by  day,  week  by  week,  month  by  month,  and  year 
by  year,  until  the  spaces  between  all  of  them  are  nearly  a  sixteenth 
of  an  inch  wide  before  it  is  time  for  them  to  be  shed.  This  indicates 
that  the  permanent  teeth  have  arranged  themselves  in  a  proper  man- 
ner to  come  into  the  mouth  regularly.  If  no  separation  of  these 
teeth  takes  place,  it  is  almost  sure  evidence  that  nature  has  been  un- 
able, for  some  reason,  to  arrange  the  permanent  teeth  in  their  proper 
positions,  and  a  case  of  irregularity  is  very  certain  to  be  the  result. 

In  the  posterior  part  of  each  jaw,  at  the  fourth  year  of  age,  it  will 
be  observed  that  quite  a  space  is  developing  for  the  first  permanent 
molars. 

The  proper  time  when  each  pair  of  teeth,  or,  I  might  perhaps  say, 
each  four  (two  in  each  jaw)  teeth,  should  be  removed  is  of  the  great- 
est importance  to  the  practitioner,  if  he  has  the  real  welfare  of  his 
young  patient's  dental  organs  at  heart.  It  must  be  remembered  that 
the  permanent  set  of  teeth — those  that  are  to  take  the  places  of  the 
temporary  ones  (ten  in  each  jaw) — depend  almost  entirely  for  their 
regularity  upon  the  proper  care  and  timely  removal  of  the  temporary 


CHILDREN  S   TEETH    AND    THEIR   TREATMENT.  93 

teeth.  This  I  know  will  be  criticised  somewhat  by  some  in  the  pro- 
fession ;  but  I  hardly  think  the  criticism  will  affect  the  truth  of  the 
statement. 

Beginning  with  the  four  central  incisors,  at  the  age  of  six  and  a 
half  years  (sometimes  earlier,  sometimes  later),  as  a  rule,  it  will  be 
found  that  they  are  becoming  loose,  so  that  at  seven  or  thereabouts 
they  will  move  around  so  easily  that  their  roots  seem  to  have  entirely 
disappeared,  and  the  permanent  teeth  will  have  either  come  in — the 
upper  outside  and  the  lower  inside  the  temporary  ones — or  they  can 
be  seen  (the  shapes  of  them)  outlined  within  the  gum.  These  are 
indications  for  removal  of  the  temporary  teeth. 

From  six  months  to  a  year  later  the  laterals  will  become  loose,  and 
their  removal  is  indicated.  At  this  time,  about  the  eighth  year,  in 
very  many  cases,  the  four  incisors  occupy  so  much  more  space  than 
the  preceding  four  did  that  great  crowding  and  more  or  less  over- 
lapping is  produced. 

The  anxiety  of  parents  is  often  very  great  for  fear  that  the  child's 
teeth  will  be  permanently  irregular  ;  so  the  child  is  taken  to  a  den- 
tist, who  is  requested  to  extract  the  cuspids  to  make  room  for  the 
four  incisors  to  become  straight  or  regular  in  position.  Should  he 
comply,  the  result  would  be  that  these  teeth  would  become  regular, 
but  at  the  sacrifice  of  a  portion  of  the  room  needed  for  the  perma- 
nent cuspids  and  a  cessation  of  the  growth  of  the  jaw.  The  pressure 
from  behind  from  the  growth  of  the  second  permanent  molar  would 
force  the  molars  (two  temporary  and  first  permanent)  forward,  so 
that  within  a  year  or  two  at  most  no  space  whatever  would  be  left  for 
the  permanent  cuspid,  which  is  due  to  erupt  some  three  years  after 
the  lateral  incisors.  In  consequence  •  the  four  cuspids  would  come 
generally  outside  of  the  arches  entirely,  and  they,  or  some  other 
permanent  teeth,  would  have  to  be  removed,  or  the  teeth  regulated,  to 
put  the  front  of  the  mouth  in  a  fairly  presentable  condition. 

The  temporary  cuspids  should,  therefore,  never  be  re^noved  to  make 
room  for  the  perm,anent  incisors.  Violation  of  this  canon  affords  one 
of  the  cases  in  which  the  growth  of  the  jaw  is  stopped  by  ignorant 
interference. 

The  next  four  teeth  to  be  removed,  in  order,  are  the  first  molars,  at 
about  the  tenth  year  ;  the  space  occupied  by  these  teeth  is  somewhat 
greater  (about  one-sixteenth  of  an  inch  each)  than  is  required  for  the 
permanent  first  bicuspids,  which  are  to  take  their  places.  This  space 
is  partly  appropriated  by  the  front  teeth,  which  are  forcing  themselves 
into  correct  positions  as  opportunity  offers. 

About  a  year  later,  at  eleven  years  of  age,  the  temporary  cuspids 
should  be  removed.  The  permanent  ones,  which  are  now  about 
erupting,  are  about  one-sixteenth  of  an  inch  broader  than  the  spaces 


94  DENTAL  PATHOLOGY  AND  PRACTICE. 

made  vacant  for  them  ;  consequently  they  are  slow  in  coming  into 
position.  The  work  of  nature,  always  to  be  relied  upon  if  not  inter- 
fered with,  will  manifest  itself  again  by  a  constant  growth  of  the 
maxillas  and  alveoli,  so  that  at  twelve  years  of  age,  when  the  second 
temporary  molars  are  removed, — which  occupy  about  one-eighth  of  an 
inch  more  room  each  than  is  required  for  the  permanent  second  bi- 
cuspid,— the  six  front  teeth  will,  from  growth  of  the  jaws,  have  so 
nearly  regulated  themselves  that  their  complete  regulation  is  effected 
by  crowding  the  first  bicuspid  back  into  this  extra  space  in  a  compara- 
tively short  time,  and  the  mouth  will  present  one  of  the  most  beauti- 
ful works  of  the  Creator, — a  regular  set  of  teeth. 

During  the  twelfth  year  the  second  permanent  molar  will  have 
come  in,  as  a  rule  ;  and  from  sixteen  to  twenty-four,  or  later,  the 
third  molar  (wisdom-tooth)  will  worry  itself  through  the  gum. 


CHAPTER    IX. 


MICROSCOPICAL  STUDIES  UPON  THE  ABSORPTION  OF  THE  ROOTS 
OF  TEMPORARY  TEETH.* 

The  fact  that,  previous  to  the  appearance  of  the  permanent  set,  the 
roots  of  the  temporary  teeth  have  partially  or  entirely  disappeared, 
leaving  their  crowns — inverted  cup-shaped — held  in  place  by  slight 
attachment  of  the  gum  to  the  necks  of  the  teeth  only,  has  long  been 
known  to  observers.  It  has  never  been  doubted  that  a  persistent, 
though  graded,  irritation  causes  the  disappearance  or  absorption  ;  but 
what  the  exact  cause  in  every  instance  of  this  irritation  is,  we  cannot 
tell.  The  idea  that  in  all  cases  the  pressure  of  the  growing  permanent 
tooth  is  the  direct  cause  must  be  abandoned,  since  clinical  observation 
shows  that  the  absorption  of  a  temporary  tooth  may  take  place  though 
far  distant  from  the  permanent  one  ;  nevertheless,  we  maintain  that 
its  growth  and  impingement  upon  the  periosteum  of  the  temporary 
tooth  in  most  cases  directly  causes  the  irritation  and  consequent  ab- 
sorption. 

The  assertion  of  Tomes  that  it  is  due  to  the  presence  of  freely 
vascularized  papilla  does  not  explain  the  decrease  of  the  dental 
tissues,  for  the  papilla  is  nothing  but  medullary  tissue,  such  as  we 
meet  with  in  any  part  of  the  organism  where  one  tissue  is  about  to 
change  into  another.  Such  a  papilla  can  be  the  cause  of  the  absorp- 
tion,  as  well  as  its  result.     Another  assertion,   that  the  meduUary^ 

*  Abbott,  Independent  Practitioner ,  1884. 


ABSORPTION   OF   THE    ROOTS    OF   TEMPORARY   TEETH.  95 

cells  eat  out  the  dental  tissues  by  their  active  growth,  or  by  their 
ameboid  motions,  is  insufficient  for  the  explanation  of  the  loss  of  the 
lime-salts  in  the  dental  tissue,  the  presence  of  circular  or  semi-circular 
excavations  and  bays,  so  characteristic  of  the  melting  process  of  the 
cementum  and  dentine  of  deciduous  teeth. 

Since  we  know  that  pieces  of  dead  bone  or  ivory  may  be  absorbed, 
producing  in  them  an  appearance  similar  to  those  found  on  the  surfaces 
of  temporary  teeth,  the  idea  possibly  becomes  admissible  thatj  owing 
to  the  presence  of  an  acid,  first  the  lime-salts  are  dissolved  out  within 
certain  territories  of  the  dead  bone -tissue  in  a  merely  chemical  or 
passive  way,  whereupon  the  soft  medullary  tissue  penetrates  the  spaces 
thus  established.  Quite  different,  however,  will  be  the  conception  of 
this  process  if  we  bear  in  mind  that  the  temporary  as  well  as  the  per- 
manent teeth  are  made  up  of  living  tissues,  and  that  an  active  partici- 
pation of  these  tissues  must  be  expected  in  the  process  of  transforma- 
tion of  the  dental  into  medullary  tissue.  As  the  process  of  absorption 
is  closely  allied  to  the  process  of  inflammation,  and  active  changes 
of  the  dental  tissues  have  been  proven,  beyond  any  doubt,  to  have 
followed  inflammation,  we  may  a  priori  expect  such  changes  of  the 
bone-tissues  of  the  temporary  teeth  in  the  process  of  absorption  also. 

I  shall  try  to  prove  that  such  changes  really  do  occur. 

In  the  light  of  the  most  advanced  modern  views  concerning  the 
structure  of  the  dental  tissues,  we  consider  cementum,  dentine,  and 
enamel  as  endowed  with  properties  of  life,  or,  in  other  words,  as 
pervaded  by  living  matter  in  the  shape  of  an  extremely  delicate 
reticulum.  In  this  view  not  only  the  cement-corpuscles  and  their 
coarser  offshoots  contain  living  matter  in  the  shape  of  so-called 
' '  granular  protoplasm, ' '  but  the  entire  basis-substance  present  between 
the  cement-corpuscles  is  alive  also,  only  the  minute  meshes  of  the 
living  reticulum  holding  a  gluey  basis-substance  saturated  with  lime- 
salts.  In  the  dentine,  not  only  the  tenants  of  the  dentinal  canaliculi 
(the  dentinal  fibers)  are  alive,  but  the  entire  mass  of  gluey  and  calci- 
fied basis-substance  between  the  dentinal  canaliculi  is  pervaded  with 
living  matter.  The  same  holds  good  for  the  enamel,  in  which  the 
delicate  fibrillae  between  the  enamel-prisms  have  been  positively 
proven  to  be  living  matter.  The  prisms  are  undoubtedly  pierced 
by  living  matter  ;  this,  however,  has  been  demonstrated  only  indi- 
rectly in  morbid  changes  of  the  enamel.  Of  the  cementum,  we 
know  that  each  cement-corpuscle  occupies  the  center  of  a  more  or 
less  globular  territory  of  basis-substance.  If,  therefore,  circular  fields 
of  absorption  appear  during  the  process  of  inflammation  and  break- 
ing down  of  the  cementum,  we  can  readily  trace  these  territories  in 
following  out  the  portion  affected  by  the  process  of  absorption.  But 
how  shall  we  explain  the  bay-like  excavations  in  the  dentine  and 


96  DENTAL  PATHOLOGY  AND  PRACTICE. 

enamel  so  often  seen  in  partially  absorbed  temporary  teeth,  where 
there  is  nothing  known  of  territories  ?  Here  the  first  difficulty  is 
found,  due  to  the  lack  of  knowledge  of  the  history  of  the  develop- 
ment of  dentine  and  enamel.  Czermak's  interglobular  spaces  indicate 
the  presence  of  such  territories  in  the  dentine,  the  presence  of  which, 
however,  can  be  proven  only  after  accurate  researches  in  the  history 
of  development. 

Granted  that  the  dissolution  of  lime-salts  takes  place  in  globular 
territories  in  the  dental  tissues,  the  next  question  will  be,  how  do  the 
medullary  elements  appear  in  such  spaces  ?  Do  they  migrate  or 
penetrate  from  without,  or  do  they  originate,  in  part  at  least,  from 
the  living  material  present  in  all  dental  tissue  ? 

Absorption  of  Cementum. 

The  process  of  absorption  of  a  provisional  tooth  begins  on  the 
cementum  of  the  roots.  The  latter  exhibits  before  the  beginning  of 
this  process  the  features  of  cementum  of  permanent  teeth.  Primarily, 
the  absorption  is  marked  by  the  appearance  of  the  well-known  fields 
so  commonly  met  with  in  the  process  of  osteitis,  that  is,  excavations 
on  the  surface,  either  semi-circular  or  composed  of  a  varying  number 
of  semi-circular  festoons,  all  of  which  are  filled  with  medullary  ele- 
ments, multinuclear  bodies,  or  a  delicate  myxomata,  in  part  bony, 
in  part  fibrous  connective  tissue,  blending  with  the  adjacent  myxo- 
matous or  fibrous  pericementum.  The  communication  of  the  exca- 
vations with  the  pericementum  is  either  widely  gaping  or  through  a 
narrowed  neck  on  the  surface  of  the  cementum.  Sometimes,  how- 
ever, in  the  sections  the  excavations  appear  isolated,  without  any 
communication  with  the  surface,  which  latter  instance,  however,  will 
certainly  not  permit  us  to  deny  the  existence  of  such  a  communica- 
tion on  a  plane  above  or  below  that  of  the  section.  In  the  excavations 
the  cementum  is  unquestionably  reduced  first  into  medullary,  after- 
ward into  myxomatous  or  fibrous  tissue.  By  closely  watching  exca- 
vations of  a  more  recent  date  at  the  periphery  of  those  in  communi- 
cation with  the  pericementum,  we  notice  that  the  lime-salts  and  the 
basis-substance  proper  are  missing,  and  are  replaced  by  a  uniformly 
granular  protoplasm,  or  a  varying  number  of  faintly^jnarked  medul- 
lary elements,  each  of  which  may  contain  a  central  nucleus.  We 
can  trace  a  gradual  change  of  the  tissue  of  cementum  from  a  disso- 
lution of  lime-salts  to  the  appearance  of  a  mass  of  granular  proto- 
plasm, and  at  last  to  the  formation  of  medullary  corpuscles.  The 
circular  shape  of  the  excavation  is  undoubtedly  in  all  cases  due  to 
a  breaking  down  of  the  lime-salts,  and  afterward  a  liquefying  of  the 
basis-substance  proper,  within  the  territory  of  a  cement-corpuscle. 
Sometimes  we  see  an  enlarg-ement  of  the  lacuna  and  the  cement-cor- 


ABSORPTION    OF   THE    ROOTS   OF   TEMPORARY   TEETH. 


97 


puscle  itself,  the  latter  splitting  up  into  a  varying  number  of  glistening 
lumps,  which  are  readily  stained  by  an  ammoniacal  solution  of  car- 
mine. In  other  instances  the  entire  territory  of  a  cement-corpuscle 
is  transformed  into  protoplasm,  and  the  reappearance  of  such  proto- 
plasm is  traceable  through  broad  offshoots  to  neighboring  cement- 
corpuscles.  In  still  other  instances  a  varying  amount  of  the  territory 
assumes  a  delicate  fibrous  appearance,  caused  by  an  early  grouping 
of  the  medullary  corpuscles  into  fibrillse.  In  neither  of  these  instances 
will  it  be  doubted  that  the  cement-corpuscles  themselves,  or  the  living 
matter  held  in  their  territories,  have  in  an  active  way  taken  part  in 
the  reappearance,  first  of  protoplasm,   and  afterward  of  medullary 

Fig.  45. 


tFC 


Absorption  of  Cementum. 
C,  cementum,  whose  corpuscles  are  in  part  in  a  process  of  division  ;  F",  the  basis-substance 
of  cementum  transformed  into  a  delicate  fibrous  tissue,  in  connection  with  a  considerably  en- 
larged and  split  up  cement-corpuscle ;  Af,  multinuclear  protoplasmic  mass,  sprung  from  the 
cementum  after  liquefaction  of  its  basis-substance.  The  large  offshoots  of  this  mass  show 
the  process  of  transformation  of  the  basis-substance  into  medullary  corpuscles ;  I^C,  fibrous 
connective  tissue,  the  result  of  the  liquefaction  of  cementum.     Magnified  500  diameters. 


corpuscles.  The  theory  that  immigrated  medullary  corpuscles,  or 
"  leucocytes,"  have  replaced  the  former  cement-tissue  must  be  aban- 
doned so  soon  as  we  can  trace  a  gradual  transformation  of  the  tissue 
of  the  cementum  into  medullary  tissue.  The  latter  immediately 
assumes  the  characteristic  features  of  a  myxomatous  or  fibrous  con- 
nective tissue  in  connection  with  the  pericementum.  (Fig.  45.) 
From  this  point  of  view  there  is  no  difficulty  in  explaining  the 

8 


98 


DENTAL   PATHOLOGY   AND    PRACTICE. 


appearance  of  multinuclear  bodies,  so-called  "  myeloplaxes,"  in  the 
dissolved  territories.  We  know  that  such  formations  represent  a 
stage  of  development  of  cementuni,  and  they  simply  reappear  when 
the  basis-substance  of  an  already- formed  cementum  is  dissolved  or 
liquefied.  In  fact,  nothing  else  is  required  but  a  reformation  of  basis- 
substance  and  its  recalcification,  in  order  to  reproduce  new  bony 
tissue,  such  as  we  often  meet  with  on  the  periphery  of  absorbed  ce- 
mentum. 

The  next  result  of  the  absorption  is  a  myxomatous  or  fibrous  con- 
nective tissue,  freely  supplied  with  newly-formed  blood-vessels.  In 
this  tissue  an  active  new  formation  of  bone  trabeculse  takes  place, 

Fig.  46. 


Absorption  of  Neck  of  Tooth. 

N,  dentine  of  neck  of  tooth  not  supplied  with  canaliculi ;  D,  canaliculi  of  dentine  stopping 
short  of  the  surface  of  the  neck  ;  B,  bay-like  excavations  in  the  middle  of  dentine,  filled  with 
a  pale  and  finely  granulated  protoplasm,  nuclei  beginning  to  appear;  C,  excavation  filled  with 
coarsely  granular  protoplasm,  tending  toward  an  active  new  formation  of  medullary  corpuscles  ; 
M,  multinuclear  protoplasmic  bodies,  the  so-called  "  myeloid  cells,"  in  connection  with  fibrous 
connective  tissue  on  the  surface.    Magnified  600  diameters. 


characterized  by  the  presence  of  large  and  irregular  bone-corpuscles. 
The  widened  socket,  or  dissolving  surface  of  an  absorbing  provisional 
tooth,  is  not  infrequently  filled  with  newly-formed  bone.  The  newly- 
formed  layer  of  cementum  shows  at  places  circular  fields  (territories) 
of  bone-tissue,  each  of  which  may  contain  a  varying  number  of  bone- 
corpuscles,    or  there  may  be  a  uniform  reduction   of  the  original 


ABSORPTION   OF   THE    ROOTS    OF   TEMPORARY    TEETH.  99 

cementum,  the  boundary  of  which  is  made  up  of  regularly-arranged 
medullary  corpuscles,  so-called  "osteoblasts." 

On  the  neck  of  the  tooth  the  excavations  penetrate  not  only  the 
layer  of  the  cementum  proper,  but  also  the  layer  of  the  subjacent 
dentine,  which  we  know  to  be  destitute  of  dentinal  canaliculi.  Here 
again  we  observe  at  first  a  dissolution  of  the  basis-substance  in 
globular  fields,  which  appear  filled  at  first  with  a  finely-granular 
protoplasm,  lacking  nuclei,  afterward  with  medullary  corpuscles, 
usually  nucleated,  and  at  length  with  a  slightly  fibrillated  tissue,  the 
latter  undoubtedly  originating  from  a  splitting  of  the  medullary  cor- 
puscles into  a  number  of  delicate  spindles.  The  surface  of  the  neck 
of  the  tooth  also  exhibits  the  characteristic  bay-like  excavations, 
which  are  filled  with  nucleated  medullary  corpuscles,  or  with  multi- 
nuclear  protoplasmic  bodies.  From  what  I  have  seen,  I  cannot 
doubt  that  the  nuclei  under  all  circumstances  are  secondary  forma- 
tions, and  cannot  be  regarded  as  the  future  bone-corpuscles.  A  ter- 
ritory of  bone-tissue  will  form  only  after  the  protoplasm  has  assumed 
a  uniform  granulation,  and  the  bone-corpuscles  will  develop  out  of 
this  protoplasm,  by  an  increase  of  living  matter  at  certain  regular  in- 
tervals. The  result  of  the  absorption  and  reappearance  of  the  em- 
bryonal condition  of  the  tissues  constituting  the  neck  of  the  tooth 
is  the  formation  of  new  bone-tissue,  either  in  the  shape  of  globular 
fields  (territories)  of  newly- formed  bone-tissue  or  in  the  formation  of 
a  thin  layer  of  regularly  lamellated  bone-tissue,  blending  with  that 
formed  out  of  the  cementum  of  the  roots. 

Bbdecker,  in  his  article  on  the  distribution  of  the  living  matter 
in  the  dentinal  tissues  {^Dental  Cosmos,  1878-79),  describes  and  illus- 
trates the  neck  of  a  tooth,  calling  it  an  anomalous  formation  of 
cementum.  From  what  I  have  seen  I  cannot  doubt  that  his  figure  is 
taken  from  a  deciduous  tooth,  exhibiting  newly-formed  bone-tissue 
on  the  neck.  Unquestionably  such  bony  formations  are  not  lasting, 
but  are  reformed  into  medullary  tissue  with  the  advancing  absorption 
of  the  dental  tissues,  and  lead  to  the  formation  of  either  new  bone  or 
fibrous  connective  tissue. 

Absorption  of  Dentine. 

The  most  striking  features  in  the  dentine  of  deciduous  teeth  during 
the  process  of  absorption  are  the  bay-like  excavations  on  the  surface 
after  the  complete  disappearance  of  the  covering  cementum.  The 
excavations  contain  medullary  corpuscles,  multinuclear  bodies,  or 
fibrous  connective  tissue,  in  connection  with  the  surrounding  peri- 
cementum, or  periodonteum.  The  appearance  of  such  fields  in  the 
dentine  gave  rise  to  the  theory  that  a  foreign  tissue  grows  into  the 
dentine,  destroying  it  in  the  manner  in  which  dead  bone  is  destroyed. 


lOO  DENTAL    PATHOLOGY    AND    PRACTICE. 

If,  however,  we  bear  in  mind  that  the  tissue  of  dentine  is  composed  of 
globular  territories,  the  same  as  that  of  bone,  we  are  at  once  in  position 
to  understand  the  striking  appearance  of  globular  fields  of  absorption 
in  the  dentine.  The  only  question  can  be,  is  the  dentine  absorbed  in  a 
merely  passive  way,  or  does  it  share  in  the  formation  of  medullary  tissue  ? 
The  results  of  my  researches  point  strongly  in  the  latter  direction. 
In  several  instances  I  have  been  able  to  trace  a  slight  widening  of 
the  dentinal  canaliculi  on  the  border  of  the  fields  of  absorption,  with 
an  increase  of  living  matter  in  the  canaliculi.  Such  features  are  very 
common  in  the  process  of  caries,  where  the  dilatation  of  the  canaliculi 
at  the  expense  of  the  intervening  basis-substance,  and  a  new  forma- 

FiG.  47. 


Absorption  of'  Dentine. 
D,  dentine  provided  with  unchanged  canaliculi ;  By  bay-like  excavation  in  the  dentine,  con- 
taining finely-granular  protoplasm,  which  is  about  to  form  medullary  corpuscles  ;  F,  medullary 
corpuscles  elongated  and  split  into  delicate  spindles,  the  future  fibrous  connective  tissue ;  M, 
globular  protoplasmic  masses,  the  predecessors  of  globular  territories  of  bone-tissue ;  G, 
globular  territories  of  bone-tissue,  with  central  bone-corpuscles ;  L,  iamellated  bone-tissue 
surrounding  the  outer  surface  of  the  absorbed  tooth,  or  the  inner  surface  of  its  socket. 
Magnified  600  diameters. 


tion  of  medullary  elements  out  of  the  tenants  of  the  canaliculi,  is  a 
very  common  occurrence,  when  the  caries  attacks  the  living  dentine. 
Circumscribed  bay-like  excavations,  such  as  are  common  in  absorption 
of  dentine,  I  have  frequently  met  with  in  caries. 

Sometimes,  in  caries,  such  excavations  form  independently  of  the 
surface  destruction,  under  which  circumstances,  with  lower  powers 
of  the  microscope,  even  a  well-trained  eye  would  experience  difficulty 
in  discriminating  between  carious  destruction  and  absorption  of  tem- 
porary dentine.  Higher  powers,  to  be  sure,  reveal  the  presence  of 
micro-organisms  in  the  former  process,   which  are  lacking  in  the 


ABSORPTION    OF    THE    ROOTS    OF    TEMPORARY    TEETH.  lOI 

latter.  The  first  step  seems  to  be  identical  in  both  ;  a  dissolution 
of  the  lime-salts,  or  their  displacement,  by  the  liquefaction  of  the  glue- 
giving  basis-substance.  After  this,  medullary  elements  arise  out  of 
the  liquefied  dentine,  which  are  destined  to  decay  in  caries,  and,  on 
the  contrary,  proliferate  in  the  process  of  absorption,  with  the  result 
of  the  new  formation  of  medullary  tissue.  In  caries  the  process  of 
softening,  or  the  removal  of  the  calcific  basis-substance,  results  in  the 
death  and  putrefaction  of  the  tissue.  In  the  process  of  absorption, 
on  the  contrary,  it  ends  in  an  active  proliferation  of  medullary  tissue. 

The  result  of  the  latter  process  is  the  same,  whether  it  occurs  on 
the  cementum,  on  the  neck  of  the  tooth,  or  in  canalicularized  den- 
tine. The  newly-formed  medullary  tissue  consists  either  of  single 
medullary  corpuscles,  usually  with  one  oblong  and  faintly-marked 
nucleus,  or  in  the  shape  of  larger  protoplasmic  masses  with  a  varying 
number  of  oblong  nuclei,  so-called  "  myeloid  cells."  At  the  border 
of  the  bays  I  have  sometimes  been  able  to  trace  delicate  thorny  pro- 
jections from  the  multinuclear  masses  into  the  unchanged  basis-sub- 
stance of  the  dentine.  Sometimes  I  have  seen  broad  offshoots  of 
the  multinuclear  bodies  penetrating  the  widened  dentinal  canaliculi, 
and  in  direct  union  with  the  dentinal  fibers.  The  latter  feature, 
especially,  seems  to  point  strongly  toward  an  organic  connection 
between  the  unchanged  and  the  dissolved-out  dentine. 

The  multinuclear  bodies  are,  as  is  well  known,  the  future  territories 
of  bone-tissue,  and  therefore  its  predecessors.  The  formation  of 
bony  territories  can  easily  be  traced  on  the  surface  of  absorbed  den- 
tine. Just  as  in  normal  development  of  bone-tissue  globular  terri- 
tories first  appear,  and  afterward  lamellated  bone-tissue,  so  also  in 
absorbed  dentine,  first  multinuclear  bodies,  afterward  globular  terri- 
tories of  bone-tissue,  and  at  last  lamellated  bone-tissue  forms  on  the 
surface,  the  latter  producing,  in  many  instances,  a  continuous  layer  of 
bone  all  around  the  absorbed  tooth.  This  feature  was  correctly  ob- 
served and  described  by  Tomes. 

As  to  absorption  of  the  enamel  I  can  say  but  little.  It  is  well 
known  that  bay-like  excavations  are  seen  in  this  tissue,  in  no  way 
differing  from  those  of  dentine  and  cementum.  From  this  fact  it 
would  follow  that  all  the  theories  hitherto  advanced  with  regard  to  the 
development  of  enamel  must  be  erroneous,  and  that  there  must  be 
an  arrangement  in  the  enamel-forming  tissue  leading  to  the  pro- 
duction of  territories  in  a  manner  similar  to  that  of  dentine  and 
cementum.  It  seems  that  the  process  of  destruction,  starting  on 
the  surface  of  the  enamel,  is  in  all  instances  caries,  and  not  absorp- 
tion. The  latter  process  attacks  enamel  only  from  within.  After 
most  of  the  dentine  has  been  absorbed  and  transformed  into  myxo- 
matous tissue,  the  enamel  is  attacked  and  thinned  to  a  varying  degree 


I02  DENTAL    PATHOLOGY   AND    PRACTICE. 

by  the  same  process.  Thus  it  becomes  inteUigible  that  the  shell  of 
enamel  left  is  coated  by  a  layer  of  lamellated  dentine,  which  is  con- 
tinuous all  around  the  remnants  of  the  provisional  tooth. 

Since  we  know  that  enamel  is  a  live  tissue  in  a  living  tooth,  we 
may  anticipate  its  reduction  into  medullary  tissue  in  the  process  of 
absorption.  Whether  or  not  such  a  breaking  down  of  enamel  occurs, 
with  its  consequent  participation  in  the  formation  of  bone-tissue,  I 
am  unable  to  say. 


CHAPTER   X. 

FILLING   TEETH. 


So  much  has  been  said  and  written  upon  this  always-interesting 
subject  that  I  propose  in  this  short  chapter  to  discuss  only  special 
features  peculiar  to  my  individual  work.  That  the  preservation  of 
the  human  teeth  and  mouth  from  ravages  of  disease  is  as  laudable  an 
undertaking,  and  demands  of  those  following  the  practice  as  much  of 
everything  that  goes  to  make  up  a  cultivated  and  high-toned  gentle- 
man as  any  calling  or  profession  known  to  the  human  family,  I  think 
will  hardly  be  questioned.  That  the  time  of  a  busy  dental  surgeon 
is  occupied  more  in  the  work  oi  filling  teeth  than  it  is  in  all  other 
branches  of  his  specialty,  I  think  all  will  agree.  That  it  is  most 
desirable  that  this  shall  be  accomplished  in  the  best  manner,  with 
the  greatest  dispatch,  with  the  least  discomfort  to  the  patient,  and 
with  the  least  nervous  wear  and  tear  upon  the  practitioner,  I  believe 
will  be  admitted  by  all. 

There  is  probably  no  vocation  in  which  more  individuality  is  con- 
stantly coming  to  the  front  than  is  found  among  practitioners  of 
dental  surgery.  In  one  sense  this  is  an  encouraging  feature,  as  it  de- 
velops the  latent  talent  of  each  individual  ;  in  another,  perhaps  not  so 
encouraging.  All  men  are  not  born  with  the  same  amount  of  talent 
in  any  given  direction  ;  nor  can  any  given  class  be  educated  in  any 
profession  or  trade  to  the  standard  of  perfect  equality  ;  consequently, 
some  will  lead,  and  others  must  follow.  This  fact  has  been  very 
markedly  exemplified  in  our  specialty  during  the  past  thirty  years  ; 
probably  in  nothing  we  do  more  than  in  filling  teeth. 

It  will  be  remembered  by  the  older  readers  that  some  thirty- odd 
years  ago,  cohesive  and  crystal  gold  were  introduced  by  one  of  our 
eminent  practitioners,  and  with  these  came  the  contouring  of  teeth 
with  gold.  Following  close  upon  this  came  the  hand-mallet,  first 
used  by  one  gentleman,  and  afterward  introduced  by  another.  With 
these  implements  in  hand,  every  practitioner  tried  to  become  a  tooth- 


FILLING  TEETH. 


103 


restorer  at  once.  The  most  of  us  found,  however,  that  time  and 
much  experience  were  necessary  in  order  to  successfully  restore  a 
crown  upon  a  tooth  in  the  mouth.  We  soon  learned  that  we  were 
not  all  William  H.  Dwindles,  nor  all  William  H.  Atkinsons.  These 
were  men  whom  the  gods  had  smiled  upon,  and  who  were  endowed 
with  the  talent  to  lead  in  any  undertaking'. 

With  cohesive  gold  and  the  mallet  much  could  be  done,  but  one 

Fig.  48. 

Set  of  Mallet-Pluggers. 


2345  67         8       9       10         II      12        13      14       15       16     17       18 


deficiency  in  the  armamentarium  of  the  ambitious  dental  surgeon 
was  quickly  made  apparent, — viz,  proper  instruments  to  manipulate 
the  gold  with.  Dr.  Atkinson  was  the  first  in  the  field,  in  the  year 
1863,  with  a  set  of  twelve  points,  which  were  good,  some  of  them 
being  in  constant  use  to-day.  In  the  winter  of  1866-67  there  appeared 
another  set  of  thirty-six  points  (Fig.  48),  under  the  name  of  the  present 
author,  and  subsequently  some  ten  or  fifteen  smaller  sets  of  mallet- 
pluggers  were  introduced  by  different  parties,  then   a  set  of  hand- 


I04 


DENTAL  PATHOLOGY  AND  PRACTICE. 


Fig.  49. 

Hand-Burnishing  Pluggers. 


III 


pluggers  by  the  author,  and  later  the  burnishing  pluggers  (Fig.  49). 
The  hand-mallet  was  thought  by  some  to  be  too  troublesome,  because 
of  its  necessitating  the  constant  presence  of  an  assistant,  which  was 

seriously  objected  to  by  not  a  few 
patients.     This  led  to  the  inven- 
tion of  the  automatic  mallet,  which 
entirely  did  away  with  the  need  of 
an    assistant  for   those  who   used 
it,     except    in    very    troublesome 
cases.     Subsequently,    the   pneu- 
matic,   the    electric,    the    engine, 
and  other  mallets  were  introduced, 
with  the  same  object  in  view, — viz, 
to  facilitate  the  rapid  and  perfect 
introduction  of  gold  into  cavities 
in  teeth  and  the  contouring  of  their 
crowns. 
The  work  preliminary  to  the  introduction  of  the  filling- 
material  is  often  of  more  importance  than  the  actual  placing 
of  the  filling,   to  both  operator  and  patient,   especially  to 
the  latter.     If  approximal  cavities  are  to  be  filled,  the  ques- 
tion of  room  to  properly  work  in  is  very  important,   and 
should  be  carefully  studied,  to  the  end  that  it  shall  be  surely 
secured  and  in  such  way  that  the  least  discomfort  to  the 
patient  shall  be  caused,  and  the  best  results  from  the  opera- 
tion be  obtained.    In  my  judgment,  the  rapid  wedging  apart 
of  the  teeth,  except  in  the  mouths  of  children  under  fifteen 
years  of  age,  is  not  the  best  way.     When  the  bones  (alve- 
olus) around  the  teeth  have  become  matured,  the  only  space 
that  can  at  once  be  secured  between  them  with  safety  is  what 
can  be  made  by   so  much  condensation  as  the  periosteum 
can  be  safely  subjected  to  on  either  distal  side  of  the  root  at 
the  necks,  with  slight  condensation  upon  the  other  side  at 
the  apex  of  the  root.     Any  force  beyond  what  is  required 
to  accomplish  this,  must  of  necessity  either  spring  or  frac- 
ture the  alveolus.     If  the  former,  long-continued  operations 
are  liable  to  result  in  severe  periosteal  inflammation,  if  not 
in  the  death  of  the  pulp  ;  if  the  latter,  not  only  is  the  death 
of  the  pulp  very  likely  to  supervene,  but  necrosis  of  the 
alveolus  may,  as  it  sometimes  does,  follow.      I  have  now 
under  treatment  a  case  of  fracture  of  the  alveolus  from  the 
use  of  a  separator,  and  another  of  injury  to  the  periosteum. 
By  a  slow  process  of  wedging,  these  troubles  are  almost  sure 
to  be  avoided.     Slow  wedging  may  be  accomplished  by  the  use  of 


FILLING    TEETH. 


105 


fl 


i 


m 


mi 

m. 


cotton  packed  tightly  between  the  teeth,  and  its  daily  renewal,  a  larger 
piece  being  used  every  succeeding  day  until  enough  space  is  gained. 
Narrow  tape  may  be  used  in  the  same  manner, — i.e.,  one  thickness 
being  placed  between  the  teeth  at  first ;  then,  by  doubling  the  tape 


Fig.  50. 

Set  of  Enamel  Chisels  and  Hatchets. 


each  day,  room  enough  will  be  secured  in  two  or  three  days.  Rubber 
placed  between  the  teeth,  very  thin  the  first  day,  and  a  little  thicker 
each  succeeding  day  until  sufficient  space  is  obtained,  will  be  found 
very  satisfactory. 

After  the  teeth  are  separated  in  the  manner  described,  the  space 
made  need  be  only  enough  to  give  room  for  finishing;  a  wedge  of 
gutta-percha  or  wood  must  be  substituted  for  the  expansive  material 
and  left  in  position  until  the  periosteal  soreness  has  subsided,  before 
the  tooth  is  filled. 

In  discussing  the  subject  of  preparing  a  cavity  for  receiving  and 
retaining  the  filling-material,  I  shall  confine  myself  to  a  few  general 
points. 

Enamel  chisels  or  hatchets  (Fig.  50)  are  commonly  the  first  instru- 
ments used  in  the  preparation  of  cavities  for  filling.  The  above  set  I 
had  the  honor  of  introducing  to  the  profession  many  years  ago,  and 
have  never  had  occasion  to  modify  it.  The  curved  chisels  are  found, 
aside  from  the  work  for  which  they  were  designed,  most  useful  in 
removing  tartar  from  the  back  teeth,  both  above  and  below,  and  the 
straight  ones  for  trimming  gold  fillings  in  front  teeth. 

The  shape  of  a  cavity  in  a  tooth  should  be  such  that  the 
filling  shall  be  firmly  held  in  place,  and  at  the  same  time  sufficient 
strength  of  tooth  should  be  retained  for  the  service  to  which  the 
tooth  is  to  be  subjected.  For  instance,  much  more  strength  of  tooth 
around  a  filling  is  required  in  a  molar  than  in  an  incisor,  on  account 
of  the  greater  force  expended  in  masticating  done  by  molar  teeth  as 


Io6  DENTAL   PATHOLOGY  AND    PRACTICE. 

compared  with  that  of  the  cutting  done  by  the  incisors.  In  this 
connection  a  study  of  mechanics  is  of  the  greatest  service  to  a  dental 
surgeon. 

It  must  always  be  borne  in  mind  that  teeth  are  living  organs,  and 
subject  to  reaction  under  irritation  the  same  as  other  portions  of  the 
living  organism.  When  this  is  well  understood,  it  will  be  easy  to 
appreciate  the  fact  that  carious  teeth,  if  the  pulps  be  alive,  are  more 
or  less  inflamed  and  their  sensitiveness  increased,  not  only  in  the 
immediate  cavity  of  decay,  but  throughout  their  entire  substance  ; 
the  intensity  of  the  action  being  somewhat  dependent  upon  the  size  of 
the  carious  cavity,  and  upon  whether  the  caries  is  of  the  acute  or 
chronic  variety.  The  larger  the  cavity  and  the  more  acute  the  dis- 
ease, the  more  intense  will  be  the  inflammation  and  soreness,  and  the 
more  generally  will  they  be  diifused  throughout  the  tooth-structure. 

Many  substances  have,  at  different  times,  been  introduced  and 
used,  as  secret  preparations,  to  obtund  this  sensitiveness,  with  very 
little  real  relief  to  the  patient.  These  include  escharotics  (chlorid 
of  zinc  in  crystals,  and  a  mixture  of  caustic  potash  with  carbolic 
acid)  ;  a  cooked  preparation  of  tannic  acid  and  glycerin,  to  which  is 
added  a  small  percentage  of  chloroform  ;  different  preparations  of 
muriate  of  cocain,  camphor,  cannabis  indica,,  aconite,  etc. 

After  a  somewhat  protracted  trial  of  each  of  them,  I  have  invaria- 
bly returned  to  the  alkaline  treatment,  with  which  I  have  obtained 
the  most  satisfactory  results  for  the  past  twenty-five  years.  The  most 
reliable  and  most  convenient  substance  for  this  purpose  is  sodae  bi- 
carb. ,  used  as  follows  :  For  the  first  day  a  solution  of  3J  to  water 
§viij  is  used  to  rinse  the  mouth  thoroughly  every  hour  ;  the  second 
day  the  strength  of  the  soda  is  doubled,  and  it  is  used  in  the  same 
manner  ;  and  the  third  day  the  dry  soda  is  packed  into  the  cavities  of 
decay  six  or  eight  times.  This  is  also  done  the  last  thing  before 
retiring  at  night,  and  the  soda  left  in  the  cavities.  In  most  cases, 
under  this  treatment,  the  teeth  will  be  found  on  the  fourth  day 
almost  without  sensation.  The  tooth  in  its  physiological  state  is  only 
slightly  sensitive  when  cut  with  an  instrument.  This  condition  is 
alkaline.  Presuming  that  acids  are  the  irritant,  the  physiological 
condition,  so  far  as  the  irritating  effect  of  acid  is  concerned,  is  so  nearly 
restored  by  neutralizing  them  that  the  extreme  soreness  of  the  carious 
portion  has  disappeared. 

In  many  cases,  it  is  found  that  by  the  removal  of  all  the  decalcified 
or  partially  decalcified  dentine  the  pulp  becomes  exposed.  This 
should  be  studiously  avoided,  as  the  natural  covering  of  the  pulp, 
the  dentine,  even  though  it  be  more  or  less  affected  by  the  carious 
process,  is  much  better  than  an  artificial  covering,  no  matter  how 
non-irritating  it  may  be,  or  how  delicately  and  perfectly  it  may  be 


FILLING   TEETH.  I07 

applied.  After  having  prepared  a  cavity  of  this  description  in  every 
direction  except  toward  the  pulp,  a  round,  broad-pointed  hatchet 
excavator  should  be  used  to  scrape  off  the  softest  portion  of  the  de- 
calcified dentine  in  this  direction.  A  paste  of  precipitated  chalk  and 
wood  creasote  is  then  spread  over  that  portion  of  the  cavity,  and  a 
capping  of  zinc  phosphate  put  upon  it,  upon  which  the  filling  proper 
may  be  placed.  The  creasote-and-chalk  paste  is  used  because  it 
combines  alkaline,  sedative,  and  preservative  or  antiseptic  properties. 

I  wish  to  impress  most  thoroughly  the  importance  of  a  clear  appre- 
ciation of  the  fact  that  to  acids,  primarily,  is  due  the  greater  propor- 
tion of  irritation  in  the  mouth,  both  of  the  mucous  membrane  and 
of  the  teeth  themselves.  Therefore,  to  keep  the  mouth  constantly  in 
a  neutral  or  alkaline  condition  should  be  the  aim.  This  may  be  done 
by  using  alkaline  washes — say  of  bicarb,  soda  or  bicarb,  potash  3J  to 
water  §viij — several  times  daily,  and  especially  just  before  retiring, 
-This  may  often  be  supplemented  to  advantage,  where  excessive  acidity 
exists,  by  administering,  internally,  tablets  of  either  of  the  substances 
named,  five  grains  each,  one,  two,  or  three  times  a  day.  Salicylate 
of  soda  in  ten-grain  doses,  in  capsules,  thrice  daily,  will  be  found  of 
benefit. 

The  dififerent  preparations  of  magnesia  are  of  great  service  as 
antacids,  viz  : 

Carbonate  or  calcined — Dose  of  either  9j  three  times  a  day. 

Milk  of — Teaspoonful  three  times  a  day.  Also  used  as  a  mouth- 
wash in  water. 

Aqua  calcis,  as  a  wash  for  the  mouth,  or  taken  in  teaspoonful  doses 
three  times  a  day,  is  found  of  value. 

Rochelle  salts  (sodae  et  potassae  tartras)  is  old,  but  generally  reli- 
able as  an  antacid  when  taken  internally  in  small  doses  at  frequent 
intervals, — a  teaspoonful  in  a  glass  of  water  three  or  four  times  a  day. 

All  the  above  have  more  or  less  of  a  diuretic  effect  ;  the  magnesia 
or  Rochelle  salts,  taken  too  frequently  or  in  larger  doses,  produce  a 
very  decided  laxative  effect. 

Keeping  out  saliva  while  introducing  the  filling  is  a  most  important 
step  as  regards  the  quality  of  the  completed  operation.  Whether 
the  gold  is  merely  moistened  or  emphatically  inundated,  the  effect 
upon  the  filling  is  practically  the  same.  In  most  cases  where  saliva 
enters  the  cavity  and  gets  upon  the  surface  of  the  gold  foil  during  an 
operation,  the  various  layers  fail,  because  of  the  presence  of  the 
salivary  corpuscles,  to  come  in  sufficiently  intimate  contact  with  one 
another  to  make  a  homogeneous  filling,  and,  as  a  consequence,  it  is 
more  porous  than  it  should  be,  and  easily  breaks  apart,  portions 
coming  away  from  time  to  time  until  the  cavity  is  again  empty. 

Many  devices  have  been  resorted  to  by  ingenious  practitioners  to 


loS  DENTAL    PATHOLOGY  AND    PRACTICE. 

secure  the  desired  "  dry  spell"  while  operating  in  all  cases.  From 
the  old-fashioned  spoon-shaped  "tongue-holder"  to  "duct-com- 
pressors," and  from  those  to  the  "rubber-dam,"  were  long  steps 
ahead  in  the  accomplishment  of  this  end  ;  but  even  with  the  rubber- 
dam  some  were  not  satisfied,  as  its  use  is  accompanied  by  several 
more  or  less  unpleasant  features.  To  start  with,  in  very  many  (I 
think  the  large  majority  of)  cases,  it  is  very  troublesome  to  properly 
adjust,  the  time  occupied  in  this  part  of  the  work  being  frequently 
more  than  would  be  required  without  the  dam  to  insert  the  filling. 
Then  the  pain  necessarily  inflicted  upon  the  patient  is  often  severe. 
The  gum  must  be  forced  back  upon  the  roots  of  the  teeth.  The 
lips  are  stretched  and  wrenched, — for  quite  frequently  the  adjust- 
ment will  require  the  use  of  both  the  operator's  hands  within  the 
patient's  mouth  at  one  time, — until  the  delicate  cuticle  is  nearly  or 
quite  broken.  If  to  the  actual  pain  endured  be  added  the  unpleasant 
sensations  from  the  mere  presence  of  the  rubber  within  the  mouth, — 
the  odor  (which  is  offensive,  even  sickening,  to  many),  and  the  profuse 
flow  of  saliva  excited, — sometimes  finding  its  way  out  of  the  mouth 
and  over  the  clothing, — we  can  easily  understand  some,  at  least,  of 
the  reasons  why  many  patients  do  not  look  forward  to  a  visit  to  the 
dentist  with  unalloyed  pleasure. 

Then,  again,  from  the  standpoint  of  the  operator,  the  use  of  the 
rubber-dam  is  not  without  its  drawbacks.  After  the  long  struggle  to 
get  it  in  place,  during  which,  as  we  have  seen,  he  may  hurt  his 
patient  unmercifully,  he  is  continually  anxious  lest  it  do  not  remain 
until  the  operation  is  finished.  He  must,  therefore,  be  constantly  on 
the  watch.  Moisture  is  wont  to  find  its  way  between  the  tooth  and 
rubber,  and  spread  itself  over  the  gold  in  the  cavity,  before  he  has 
the  first  suspicion  of  danger.  The  slightest  slipping  of  a  plugger  is 
liable  to  puncture  the  dam,  making  an  opening  through  which  saliva 
is  sure  to  flow  and  inundate  his  work  before  he  can,  with  his  most 
approved  appliances,  stop  the  rent.  The  absorption  of  light  by  the 
dam  also  is  a  serious  objection.  So  that,  altogether,  the  use  of  the 
dam  is  a  strain  upon  the  operator  which  none  but  those  with  extraor- 
dinary nerves  can  stand  without  detriment. 

After  having  tried,  more  or  less  faithfully,  every  device  ever 
brought  to  my  notice  for  keeping  moisture  out  of  cavities  during 
operations,  I  finally  returned  to  the  use  of  small  pieces  of  fine  linen, 
cut  in  squares,  some  five,  some  six,  and  some  seven  inches.  These 
are  not  hemmed,  the  edges  being  left  as  cut.  In  addition  to  these  I 
have  another  form,  about  two  by  five  inches,  made  of  old,  soft  linen. 

In  filling  any  ordinary  cavity  in  the  upper  jaw,  one  piece  six  inches 
square  is  all  that  is  used.  It  is  folded  cornerwise  so  that  the  fold 
may  easily  be   carried  back  of  a  tooth,  if  a  molar  or  bicuspid,  and 


FILLING   TEETH.  IO9 

the  thin  end  brought  outside  between  the  cheek  and  gum.  By  this 
means  the  opening  of  Steno's  duct  is  compressed  so  that  no  saliva 
will  flow  from  it  into  the  mouth  during  quite  a  long  operation.  This 
idea  is  carried  out  so  far  as  the  folding  and  adapting  of  the  little 
doily  is  concerned,  in  filling  any  of  the  upper  teeth. 

In  operations  upon  the  lower  teeth  the  fold  is  made  in  the  same 
way  ;  the  larger  end  then  folded  over  and  over  until  quite  a  mass 
(about  the  size  of  an  almond)  is  produced,  which  mass  is  placed 
under  the  tongue,  covering  the  openings  of  the  ducts  from  both  the 
submaxillary  and  sublingual  glands.  The  patient  is  then  asked  to 
place  the  index  finger  of.  the  hand  opposite  to  the  side  upon  which 
the  operation  is  to  be  done,  and  to  press  it  firmly  in  place.  In  this 
manner  the  mouth  is  easily  kept  dry  for  all  ordinary  operations.  In 
larger  fillings  in  the  lower  jaw,  in  addition  to  the  above,  two  of  the 
smaller  pieces  of  linen  are  folded  and  placed  over  the  openings  of 
Steno's  ducts,  one  in  each  cheek.  These  are  held  in  their  places  by 
the  pressure  of  the  cheeks  upon  them  when  the  mouth  is  open. 
Moisture  (saliva)  may  be  kept  from  a  tooth  in  this  manner  for  forty- 
five  minutes,  or  even  an  hour,  in  the  mouths  of  most  patients. 

The  special  advantages  derived  from  the  use  of  napkins  are  the 
time  saved,  their  reflection  of  light,  their  easy,  quick,  and  painless 
adaptation,  and  the  great  comfort  to  the  patient  during  the  operation. 

Thus  it  will  be  seen  at  once  that  for  all  ordinary  work  in  the 
mouth,  the  rubber-dam  need  not  be  used.  In  the  restoration  of  the 
crowns  of  teeth  with  gold,  however,  it  is  a  great  blessing  to  the 
patient  and  comfort  to  the  operator.  I  should  add  that  the  above 
method  requires  strict  attention  to  the  work  in  hand.  Everything 
must  be  in  readiness  before  the  operation  is  commenced.  This,  like 
most  work  of  any  kind,  must  be  systematic. 

The  manner  of  introducing  gold  into  cavities  in  teeth  will  be  best 
understood  after  a  study  of  the  instruments  for  that  purpose. 

The  automatic  mallet  (Fig.  51)  was  designed  especially  to  avoid  the 
defects  of  other  appliances  of  its  class.  It  is  simple  in  construction  and 
combines  with  the  usual  direct  blow  a  back-action  movement,  actu- 
ated by  the  same  mechanism,  so  that  with  it  gold  can  be  packed  in 
cavities  in  almost  any  position  in  the  mouth. 

The  working  parts — pivotal  latch,  tripping  mechanism,  hammer, 
and  spring — are  entirely  free  from  the  case,  being  carried  upon  a 
spindle  which  passes  centrally  through  it.  This  plan  of  construction 
avoids  friction.  Each  end  of  the  spindle  is  socketed  for  the  recep- 
tion of  the  plugger-points,  one  end  giving  the  direct  push  or  thrust- 
blow,  the  other  the  pull  or  back-blow. 

The  mallet  combines  simplicity  of  construction  with  easy,  eflective 
operation. 


no 


DENTAL    PATHOLOGY    AND    PRACTICE. 


Fig.  51. 

Automatic  Mallet  and  Back-Action  Points. 


All  the  parts  liable  to  wear  are  made  of  hardened  polished 
steel,  and  the  instrument  throughout  is  constructed  in  the 
best  manner. 

For  the  direct  blow  the  cone-socket  or  Snow  &  Lewis  points, 
either  of  which  will  fit  the  socket,  may  be  used.  For  the  back^ 
action  blow,  the  special  set  of  points  shown  in  Fig.  51  was  devised. 
It  is  believed  they  will  cover  all  requirements. 

All  mallet  plugger-points  illustrated  in  this  work  are  adapted  to 
ithis  instrument. 

The  size  and  shape  of- each  of  these  points  indicate  to  the  practi- 
tioner where  and  when  they  can  be  used  to  advantage. 

For  filling  approximal  cavities  in  front  teeth,  the  following  num- 
bers of  the  mallet-pluggers  are  used, — viz,  2,  8,  19,  20,  21,  22,  25, 

29.  33,  34,  35,  36. 

What  are  denominated  universal  points,  and  used  in  nearly  all 
cavities  in  or  near  the  front  of  the  mouth  and  in  many  in  molars,  are 
26,  28,  30. 

Fig.  52. 

Set  of  Hand-Pluggers. 


FILLING   TEETH.  Ill 

For  approximal  cavities  in  cuspids,  bicuspids,  and  anterior  por- 
tions of  molars,  12,  13,  14,  15,  16. 

For  posterior  approximal  cavities  in  molars,  17,  18,  31,  32. 

For  all  cavities  in  posterior  teeth,  the  following  points  are  quite 
universally  used,  5,  7,  9,  10. 

For  restoring  crowns  of  incisors,  cuspids,  and  bicuspids,  23,  24. 

For  antero-posterior  fissures  in  molars,  27. 

For  lateral  fissures  in  molars,  16,  17. 

Nos.  I,  3,  4,  6  are  condensing  foot-instruments,  and  No.  11  is  a 
mallet-burnisher,  very  useful,  with  a  hand-mallet,  in  more  perfectly 
solidifying  the  surface  of  the  gold  before  the  finishing  process  begins. 

The  hand-pluggers  (see  illustrations)  \vill,  upon  careful  examina- 
tion in  connection  with  the  operation  to  be  done,  readily  suggest  to 
a  receptive  mind  where  and  when  they  should  be  used.  I  may  in 
passing  remark,  however,  that  in  very  small  approximal  cavities  in 
front  teeth,  in  the  buccal  portions  of  posterior  approximal  cavities  in 
lower  bicuspids  and  molars,  in  the  anterior  portions  of  buccal  cavi- 
ties in  molars  of  either  jaw,  and  in  crozvn  cavities  in  third  molars, 
besides  many  out-of-the-way  cavities  in  different  teeth  in  the  mouth, 
they  are  indispensable  to  a  good  piece  of  work. 

The  packing  of  gold  with  round-pointed  instruments,  to  which  a 
rotary  motion  was  imparted  by  the  engine,  was  introduced  some 
years  since  by  Dr.  Wilhelm  Herbst,  of  Bremen,  Germany.  It  was 
found  upon  trial  by  the  writer  to  be  somewhat  more  laborious  work 
to  make  a  really  good  and  satisfactory  filling  in  this  manner  than  by 
others,  and  that  to  adapt  a  straight  instrument  to  most  portions  of 
cavities  in  teeth  was  very  difficult.  This  led  to  the  making  of  the 
six  burnishing-points  illustrated.  (See  Fig.  49.)  It  will  be  observed 
that  they  are  all  curved  slightly  (some  twenty  degrees)  from  a  straight 
line,  which  makes  it  easy  to  reach  nearly  all  approximal  cavities  found 
in  teeth. 

The  method  of  condensing  gold  against  the  walls  of  cavities  by 
the  burnishing  process  cannot  be  too  highly  commended,  as  it  results 
in  the  most  perfect  adaptation,  especially  where  the  walls  are  so  frail 
that  malleting  the  gold  would  be  likely  to  fracture  them.  These 
instrumicnts  are  used  to  great  advantage  in  adapting  the  gold  to  the 
cervical  portions  of  cavities,  where  quite  large  cylinders  or  rolls  may 
be  most  perfectly  compressed. 

Usually,  such  cavities  are  filled  one-fourth  or  one-third  in  this  man- 
ner, and  the  mallet  used  for  the  remainder  of  the  operation,  except 
that,  if  the  side  walls  be  thin,  the  burnishing  process  should  be  used 
to  adapt  the  gold  to  them. 

The  slight  curve  in  the  instrument  greatly  facilitates  its  use,  as  by 
a  slight  rotary  movement  the  bulb  of  the  instrument  is  made  to  slide 


112 


DENTAL    PATHOLOGY    AND    PRACTICE. 


Fig.  53. 

Carriers, 


Saw  and  File  Carriers,  for  Finishing 
Fillings,  etc.,  between  the  Teeth,  No. 
I  between  the  Front  and  No.  2  between 
THE  Back  Teeth. 


from  one  side  of  the  cavity  to  the 
other.  This  movement,  from  side 
to  side  with  strong  pressure,  is 
made  several  times  on  each  piece 
of  gold  inserted.  To  make  sure 
that  the  gold  shall  firmly  cohere,  it 
should  be  well  annealed  as  used. 

The  use  of  tin  as  a  filling-mate- 
rial for  teeth  has  been  almost  en- 
tirely superseded  by  amalgam, 
although  among  the  older  practi- 
tioners (those  who  understand  how 
to  manipulate  it)  tin  is  considered 
one  of  the  best,  if  not  the  very 
best  metal  known  for  preserving 
teeth  from  decay.  In  conse- 
quence of  its  lack  of  the  cohesive 
property,  it  is  introduced  and  re- 
tained in  a  cavity  upon  the  me- 
chanical principle  of  wedging,  the 
last  piece  serving  as  a  keystone,  or 
anchor,  to  the  whole  filling.  Each 
piece  should  fill  a  portion  of  the 
cavity  from  the  bottom  to  the  top, 
with  sufficient  tin  protruding  from 
the  cavity  to  serve  for  thorough 
condensation  and  finishing  of  the 
surface,  and  the  last  piece  inserted 
should  have  a  retaining  cavity  to 
hold  it  firmly  in  place.  The  foil 
is  prepared  by  folding  a  sheet,  or 
half  a  sheet,  and  twisting  it  into  a 
rope,  which  is  then  cut  into  suitable 
lengths  for  the  cavity  to  be  filled. 

When  amalgam  is  used  for  filling 
teeth,  the  same  careful  preparation 
of  the  cavity  should  be  observed 
as  for  gold.  This  material  has 
been  greatly  abused  in  conse- 
quence of  the  careless  work  done 
with  it.  In  preparing  the  mate- 
rial, after  a  perfect  paste  is  made, 
it  will,  I  think,  make  a  lighter-col- 
ored filling  if  washing,  either  with  alcohol,  or  soap  and  water,   is  re- 


FILLING    TEETH.  II3 

sorted  to,  by  which  process  the  silver  oxid  is  removed.  The  excess 
of  mercury  can  be  expelled  by  twisting  the  mass  in  a  piece  of  chamois 
or  a  napkin.  It  is  then  cut  in  pieces  of  the  proper  size  for  the  cavity 
to  be  filled,  and  the  filling  inserted  by  means  of  a  ball  burnisher, 
which  should  be  pressed  upon  each  piece  as  introduced,  and  the  amal- 
gam thoroughly  burnished  against  the  walls  of  the  cavity.  This  breaks 
up  the  original  crystals  which  commence  to  form  when  the  excess  of 
mercury  is  being  expelled,  and  a  new  crystalline  mass  is  formed,  fitting 
tightly  in  the  cavity.  When  the  cavity  is  full,  all  excess  should  be 
carefully  removed  (taking  care  that  the  patient  swallows  none  of  it), 
and  the  operation  left  until  a  subsequent  sitting  to  finish.  This  fin- 
ishing should  be  done  as  thoroughly  as  though  the  filling  were  of 
gold,  in  order  that  the  tooth  may  be  as  well  protected  as  possible  ; 
and  for  the  further  reason  that  if  the  operation  is  left  rough  and  pro- 
jecting out  upon  the  gum,  mercurial  poisoning  is  likely  to  follow. 
Food  will  lodge  upon  and  around  such  rough  and  projecting  masses, 
and  one  of  the  products  of  its  fermentation  is  hydrochloric  acid, 
which,  acting  upon  the  mercury,  converts  it  into  the  mild  chlorid  of 
mercury  (calomel),  an  active  poison,  and  in  some  instances  a  very 
dangerous  one.  This  is  the  same  process  which  mercury  in  blue  pill 
(blue  mass)  or  gray  powder  undergoes  in  the  stomach,  to  make  it  an 
active  remedy.  The  hydrochloric  acid  of  the  gastric  juice  acting  upon 
the  mercury  converts  it  into  a  mild  chlorid  of  mercury,  when  it  be- 
comes active.  Many  physicians  object  seriously,  on  this  account,  to 
the  use  of  amalgam  in  filling  teeth. 

Zinc  phosphate  as  a  filling-material  lacks  permanency.  For  tem- 
porary fillings,  however,  it  is  of  great  value,  as  a  tooth  never  decays 
under  it ;  and  by  occasionally  renewing  such  a  filling  in  an  extremely 
sensitive  tooth,  the  sensitiveness  may,  after  some  months,  be  so  mod- 
erated that  the  cavity  may  be  thoroughly  prepared  and.  a  metal 
filling  inserted  and  retained  with  comfort,  which  would  not  have 
been  tolerated  in  the  first  instance.  With  zinc  phosphate,  also,  very 
frail  teeth,  which  would  probably  be  lost  if  one  attempted  to  fill  them 
with  gold,  may  be  saved  for  years,  the  filling  being  renewed  from 
time  to  time  as  required.  A  tendency  of  zinc  phosphate  fillings  to 
disintegration  at  the  cervical  portions  of  cavities,  which  is  claimed  to 
be  due  to  the  excessive  alkalinity  of  the  saliva  in  that  region,  may  be 
overcome,  to  a  great  extent,  by  filling  a  part — say  one-fourth  of  cavi- 
ties extending  to  or  beyond  the  cervix — with  some  reliable  prepara- 
tion of  gutta-percha,  and  the  remainder  with  the  cement. 

Gutta-percha  is  an  excellent  filling-material  in  many  teeth.  It  fits 
into  a  cavity  perfectly,  and  where  not  subject  to  friction  will  preserve 
a  tooth  for  many  years.  Its  slight  conductibility  of  heat  and  cold 
makes  it  a  most  desirable  material  to  use  in  very  sensitive  teeth.     It 


114  DENTAL    PATHOLOGY   AND    PRACTICE. 

should  never,  however,  be  used  under  a  metal  filling,  as  the  moisture 
from  the  tooth  will  cause  it  to  expand  and  either  lift  the  filling  out  of 
its  place  or  burst  the  tooth.  As  a  temporary  filling-material  it  is  of 
great  service  in  almost  any  locality  in  the  mouth.  In  manipulating 
it  one  must  exercise  care  to  prevent  it  from  being  moved  after  it  is  in 
place  in  the  cavity,  which  is  quite  likely  to  occur  in  removing  the 
surplus  with  a  hot  instrument.  To  avoid  this,  the  gutta-percha  may 
be  cooled  when  in  position  and  made  quite  firm  by  throwing  cold 
water  upon  it  with  a  syringe,  after  which  the  surplus  can  be  cut  away 
with  a  very  sharp  instrument  without  disturbing  the  filling  in  the 
cavity.  Care  must  be  exercised,  however,  while  the  cooling  process 
is  going  on,  that  contraction  of  the  gutta-percha  is  not  allowed  to 
proceed  sufficiently  to  admit  of  leakage  around  it.  Constantly 
pressing  the  mass  into  the  cavity  by  means  of  a  broad-pointed  instru- 
ment, until  the  temperatures  of  the  filling  and  tooth  are  equalized,  will 
accomplish  the  object. 


CHAPTER    XL 

EXPOSED  PULPS  IN  TEETH,  AND  THEIR  TREATMENT. 

Notwithstanding  all  the  care  bestowed  upon  their  teeth  by  indi- 
viduals, and  the  watchfulness  of  the  attending  dental  surgeon,  caries 
will  often  penetrate  to  and  expose  the  pulp.  Up  to  the  advent  of 
arsenic  as  a  pulp-destroyer,  some  sixty-odd  years  ago  (first  used  by 
Dr.  Spooner  in  1830),  the  only  way  of  treating  a  tooth  after  it  had 
reached  this  stage  of  destruction,  was  extraction.  The  "  Hullihen 
operation,"  viz,  the  drilling  of  a  small  hole  under  the  margin  of  the 
gum  through  to  the  pulp- chamber,  leaving  the  dead  pulp  to  decom- 
pose and  drain  out  through  the  drill-hole  thus  made,  was  introduced 
by  Dr.  Hullihen  in  1845.  When  this  was  not  done,  if  the  tooth  were 
filled,  long  distressing  pain  and  abscess  invariably  resulted. 

For  many  years  after  the  use  of  arsenic  for  the  devitalization  of 
pulps  became  known,  very  little  improvement  in  the  practice  was 
made.  The  poison  was  placed  upon  an  exposed  pulp,  and  retained 
there  until  its  extreme  irritating  effect  produced  progressive  interference 
with  the  circulation  in  the  organ,  inflammation,  and  its  death.  A  filling 
was  then  placed  in  the  cavity  of  the  tooth,  leaving  the  pulp  to  putrefy 
and  poison  the  adjacent  tissues  (the  cementum,  periosteum),  and 
sometimes  the  alveolus  to  a  greater  or  less  extent,  terminating  in  a 
most  distressing  alveolar  abscess,  for  relieving  which,  at  that  time,  no 
means  was  known.     I  hardly  think  any  attempt  was  ever  made  pre- 


EXPOSED    PULPS    IN    TEETH,    AND    THEIR   TREATMENT.         I15 

vious  to  1862  to  cure  this  disease.  It  was  either  in  1862  or  1863 
that  Dr.  Wm.  H.  Atkinson  asserted  that  an  alveolar  abscess  could 
be  cured,  and  he  forthwith  demonstrated  his  manner  of  treatment, 
which  he  claimed  would  be  successful.  This  led  others  to  study  and 
experiment  in  the  treatment  of  teeth  so  affected,  until  now  it  is  com- 
mon practice,  and  the  results  are  very  gratifying. 

Many  practitioners  became  dissatisfied  with  the  accepted  treatment 
of  exposed  pulps,  and  again  began  experimenting  with  many  different 
materials  to  "  cap"  the  exposed  point,  as  bits  of  wood,  cork,  gold,  tin 
foil,  lead,  quill,  blotting  paper,  tissue  paper,  asbestos  paper,  phosphate 
of  lime,  the  membrane  covering  the  white  of  an  egg,  etc. ,  all  as  far 
as  practicable  soaked  in  creasote.  Then  gutta-percha,  oxychlorid  of 
zinc,  and  finally  zinc  phosphate  were  used.  The  qualities  necessary 
in  a  material  to  be  successfully  used  in  capping  exposed  pulps  of 
teeth,  are — 

1.  Perfect  adaptability  without  pressure. 

2.  Non-irritation. 

3.  Non-contractibility. 

4.  Non-expansibility. 

5.  Non-destructibility. 

None  of  the  materials  named  possess  all  of  these  qualities  to  per- 
fection. That  which  approaches  nearest  to  it  is  zinc  phosphate.  All 
except  gutta-percha,  oxychlorid,  and  phosphate  of  zinc  lack  the 
essential  feature  of  adaptability,  or  possess  some  other  equally  serious 
objections.  Gutta-percha  expands  under  moisture,  which  renders  it 
objectionable  ;  oxychlorid  is  severely  irritating.  It  was  found  that 
in  the  use  of  all  materials,  except  the  gutta-percha  and  zinc  cements, 
perfect  adaptation  to  the  exposed  point  of  the  pulp  was  not  secured, 
with  the  result  that  in  a  short  time  death  of  the  pulp  occurred.  Un- 
less the  material  used  is  perfectly  adapted,  the  space  left  under  it  will 
fill  with  serum  exuded  from  the  pulp,  which  almost  immediately 
commences  decomposing,  and  this,  with  the  pressure  produced  by  its 
constant  augmentation,  causes  first  a  local,  then  a  general  inflamma- 
tion of  the  organ,  after  which  death  soon  follows. 

Many  practitioners,  after  trying  the  capping  process,  and  failing 
more  frequently  than  they  were  successful,  have  returned  to  the  older 
method  of  destroying  (devitalizing)  the  pulp  with  arsenic  or  cobalt, 
cleansing  the  canals  and  filling  them,  as  the  safest,  and  as  giving  the 
least  trouble  to  themselves  and  to  their  patients. 

As  a  general  rule  of  practice  in  the  treatment  of  exposed  pulps  in 
teeth,  this  appears  to  me  most  unsatisfactory,  and  deserving  of  un- 
qualified condemnation,  because  of  the  possibilities  involved  in  such 
treatment.  First  of  all,  the  tooth  will  have  been  materially  weakened, 
its  color  changed  from  its  natural  and  beautiful  -translucent  tooth  tint 


Il6  DENTAL    PATHOLOGY   AND    PRACTICE. 

to  gray,  brown,  or  black  ;  periosteal  irritation  will  be  liable  to  super- 
vene at  any  subsequent  time,  and  unless  the  canals  are  perfectly 
cleansed  and  filled,  an  abscess  is  pretty  sure  sooner  or  later  to  mani- 
fest itself  Should  the  poison  be  left  in  the  tooth  too  long,  or  an  ex- 
cessive quantity  be  used,  the  cementum  covering  the  end  of  the  root, 
usually  some  sixteenth  of  an  inch  in  thickness,  through  which  the 
pulp  passes,  will  lose  its  vitality,  when  an  abscess  which  will  baffle 
all  attempts  at  cure,  and  the  ravages  of  which  no  one  can  positively 
prognosticate,  will  inevitably  develop. 

On  the  other  hand^  if  the  exposed  pulp  be  successfully  capped,  the 
strength  and  color  of  the  tooth  are  preserved,  no  periosteal  disturbance 
takes  place,  and  no  abscess  will  develop. 

A  tooth  with  the  pulp  exposed  recently  is  treated  as  follows  :  After 
the  overhanging  portions  of  enamel  have  been  removed,  all  carious 
(decalcified)  dentine  around  the  walls  of  the  cavity  is  carefully  cut 
away,  the  cavity  being  washed  out  frequently  with  warm  salt  water. 
When  this  has  been  satisfactorily  accomplished,  a  round,  broad- 
pointed  hatchet  excavator  (a  fine  point  is  liable  to  puncture  the  pulp, 
which  generally  proves  disastrous)  is  used  to  scrape  the  softened  den- 
tine and  other  debris  from  over  the  exposed  point,  a  little  wood  creasote 
being  frequently  applied  to  allay  any  pain  which  may  be  caused.  A 
pellet  of  cotton  saturated  with  the  drug  is  then  placed  upon  the  pulp 
and  slight  pressure  made  over  this  by  means  of  a  larger  piece  of  cotton, 
which  is  pressed  into  the  cavity.  The  dressing  as  described  is  left  in 
place  until  everything  is  in  readiness  for  the  capping  process.  To 
prepare  for  the  capping,  a  sufficient  quantity  of  phosphoric  acid  is 
dropped  upon  a  glass  slab,  and  enough  of  the  oxid  of  zinc  to  make  a 
paste  of  the  consistence  of  very  thick  cream  is  placed  conveniently 
by  its  side.  A  small  napkin  folded  into  the  proper  shape  is  now  placed 
in  the  mouth,  the  cotton  removed,  the  cavity  dried  out  with  a  bit  of 
spunk,  and  the  exposed  point  covered  with  a  thin  paste  of  creasote 
and  oxid  of  zinc.  After  removing  the  excess  of  creasote  with 
spunk,  the  capping  mixture  is  made  of  the  zinc  oxid  and  phos- 
phoric acid  and  put  into  the  cavity  so  that  it  will  flow  over  the  pulp 
without  the  least  pressure.  In  a  few  minutes  crystallization  (setting) 
•of  the  cement  will  begin.  If  it  is  desired  to  cover  it  at  once  with  a 
metal  filling,  wax,  partially  softened,  may  be  placed  over  the  capping 
to  keep  moisture  from  it  until  preparations  are  made  for  inserting  the 
filling. 

The  percentage  of  failures  under  the  treatment  above  described  is 
so  small  that  it  is  hardly  worth  mentioning.  It  is  true  that  failures 
do  occur,  but  they  are  usually  in  cases  in  which  the  pulp  has  been 
accidentally  injured  too  severely  to  readily  recover. 

It  will  be  observed  that  wood  creasote  is  recommended  to  be  used 


EXPOSED    PULPS    IN   TEETH,    AND    THEIR    TREATMENT.  II7 

in  all  cases  of  exposed  pulp,  in  preference  to  carbolic  acid  or  other 
escharotics.  The  reasons  are  several  :  Its  odor  is  less  disagreeable 
and  less  diffusive  ;  it  is  not  so  powerful  in  its  escharotic  action,  conse- 
quently does  not  endanger  the  life  of  the  pulp  ;  it  is  a  more  powerful 
antiseptic,  and  equally  good  as  a  sedative.  Its  action  when  applied 
to  the  exposed  pulp  is  first  escharotic,  and  to  this  it  is  probable  its 
sedative  action  is  principally  due. 

The  pulp  under  that  portion  which  has  been  rendered  lifeless  by  its 
action  soon  adjusts  itself  to  the  new  order  of  things  ;  new  odonto- 
blasts are  probably  formed,  or  additions  of  medullary  elements  to  the 
old  are  made,  and  repair  of  the  lesion  in  its  natural  covering  begins  ; 
so  that  in  time — though  perhaps  months,  possibly  even  years,  may 
elapse  before — secondary  dentine  is  formed,  and  the  opening  from  the 
cavity  in  the  tooth  to  the  pulp-chamber  healed.  Many  cases  of  such 
healing  have  come  under  my  observation,  but  never  under  circum- 
stances which  would  enable  me  to  determine  the  length  of  time  nature 
was  at  work  in  accomplishing  it. 

In  case  a  pulp  has  been  long  exposed,  and  more  or  less  painful, 
the  same  careful  procedure  is  followed  in  preparing  the  cavity  of  de- 
cay ;  then  a  small  shred  of  cotton  saturated  with  creasote  is  placed 
upon  the  exposed  point  of  the  pulp,  and  the  cavity  sealed  with  gutta- 
percha and  wax.  This  is  allowed  to  remain  one  or  two  days.  Upon 
its  removal,  if  the  pulp  is  found  in  good  condition,  and  no  pain  has 
been  experienced  from  it  since  the  application,  the  work  of  capping 
is  proceeded  with  the  same  as  in  a  recent  exposure. 

It  is  sometimes  found  in  cases  of  long-standing  exposure  of  the 
pulp,  that  the  cavity  of  decay  will  be  filled  or  partially  filled  with  a 
tumor  commonly  called  fungous  growth  of  the  pulp,  which  is  produced 
by  excessive  granulation  of  the  pulp-tissue,  from  irritation  of  that 
organ  through  coming  in  contact  with  the  rough  edges  of  the  broken 
dentine.  In  such  case  either  strong  tincture  of  aconite  root  (concen- 
trated tincture)  or  a  solution  (four  per  cent.)  of  muriate  of  cocain, 
on  a  small  twist  of  cotton,  is  worked  down  between  the  tumor  and  the 
side  of  the  cavity,  until  it  comes  in  contact  with  the  slender  pedicle 
by  which  the  tumor  is  attached  to  the  pulp.  In  five  or  ten  minutes 
a  sharp,  thin,  round-edged  hatchet  excavator  can  be  passed  in  by  the 
side  of  the  tumor  until  the  pedicle  is  reached,  when  a  sliding  move- 
ment of  the  instrument  severs  the  pedicle  ;  the  tumor  is  then  free  to 
be  removed.  After  its  removal  the  parts  are  washed. several  times 
with  warm  salt  water,  by  means  of  a  syringe,  when  the  treatment 
just  described  for  long-standing  exposures  is  applicable. 

In  cases  where  a  portion  of  the  pulp  has  been  destroyed  by  sup- 
puration, a  new,  sharp  bur,  somewhat  larger  than  would  readily  enter 
the  pulp-chamber,  is  used  to  cut  away  the  overlying  dentine  and  the 


Il8  DENTAL   PATHOLOGY   AND    PRACTICE. 

dead  portion  of  pulp  to  the  line  of  comparative  health.  This  may 
be  done  with  very  little  pain  if  cocain  is  first  applied  for  some  ten 
minutes  before  beginning  the  burring.  The  parts  are  then  washed 
thoroughly  with  a  solution  of  bichlorid  of  mercury,  i  to  10,000, 
after  which  the  usual  application  of  creasote  is  made  and  covered  with 
gutta-percha  and  wax.  Upon  the  removal  of  the  gutta-percha  and 
wax,  after  some  two  or  three  days,  if  it  is  found  that  the  remaining 
portion  of  pulp  is  apparently  in  good  condition,  having  been  free 
from  pain  since  the  application  of  the  creasote,  the  cavity  is  again 
washed  with  the  bichlorid  solution  and  a  pellef  of  cotton,  of  a  size 
to  comfortably  fill  the  vacant  place  in  the  pulp-chamber,  is  saturated 
with  creasote  and  placed  in  against  the  pulp.  A  metal  cap  (about 
ten  thicknesses  of  No.  4  tin  foil)  is  then  put  over  it,  and  a  filling  of 
gutta-percha  over  that.  If  quiet  reigns  for  some  months  a  more  per- 
manent filling  may  be  introduced,  with  the  expectation  that  the  tooth 
will  remain  alive  and  do  good  service  for  a  long  period  of  time. 


CHAPTER    XII. 

TREATMENT   OF  PULPLESS  TEETH. 

Until  within  a  comparatively  few  years,  there  was  no  apparently 
rational  or  successful  treatment  for  pulpless  teeth,  except  extraction. 
The  introduction  of  an  effective  treatment  for  alveolar  abscess  sug- 
gested the  possibility  of  saving  teeth  in  which  the  pulp  had  died,  or 
had  been  destroyed,  without  a  long  and  distressing  period  of  perios- 
teal disturbance  and  final  suppuration  at  the  end  of  their  roots.  This 
idea  shaped  itself  more  in  the  direction  of  probability,  as  sepsis  and 
antisepsis  became  better  understood. 

That  a  pulpless  tooth  can  be  retained  in  the  mouth  in  a  useful  and 
comfortable  condition  to  its  possessor,  would  seem  to  most  pathol- 
ogists, reasoning  from  a  pathological  standpoint,  an  improbability,  if 
not  an  impossibility. 

It  is  generally  understood  that  when  any  tissue  or  portion  of  tissue 
is  deprived  of  its  nourishment,  death  is  the  result.  The  dentine  of 
the  tooth  is  nourished  through  the  pulp  ;  consequently  when  the 
pulp  dies  the  source  of  nourishment  is  cut  off,  and  the  death  of  its 
organic  portion — some  twenty-eight  per  cent. — follows.  On  the  other 
hand,  the  cementum  covering  the  dentine  of  the  neck  and  root  is 
nourished  through  the  periosteum.  Thus  the  life  of  the  cementum 
is  retained,  by  which  means  it  retains  its  attachment  to  the  perios- 
teum and  the  tooth  is  held  in  place.      Here  we  have  the  phenomenon 


TREATMENT   OF    PULPLESS   TEETH.  II9 

of  dead  and  putrefying  tissue  directly  in  contact  with  that  which  still 
lives,  and  is  to  all  appearances  performing  its  function.  Such  a  con- 
dition, so  far  as  I  am  aware,  never  exists  in  any  other  portion  of  the 
human  organism. 

So  long  as  the  pulp-canal  is  open  and  a  channel  for  drainage  exists, 
the  conditions  are  simple  ;  but  when  the  canal  and  cavity  in  the  tooth 
are  sealed,  they  become  more  complicated.  As  stated  above,  twenty- 
eight  per  cent,  of  the  dentine  is  dead,  and  undergoing  decomposition. 
Upon  the  one  side  is  the  cementum,  the  living  matter  of  which  unites 
with  that  of  the  dentine,  which,  when  life  is  extinct,  is  still  in  the 
same  relation  to  it ;  and  on  the  other,  the  pulp-canal  sealed  tightly, 
through  which  no  gas  or  other  putrefaction  product  can  pass.  To 
overcome  these  conditions  is  an  achievement  in  surgery  which  is  quite 
remarkable,  and  I  believe  has  no  parallel. 

The  manner  of  treating  such  cases  has  long  occupied  much  of  the 
thought  and  study  of  the  writer.  Until  within  the  past  eight  years 
the  usual  treatment  was  to  open  the  pulp-chamber  thoroughly,  so 
that  ready  access  to  the  canal  or  canals  was  secured,  which  in  turn 
were  cleansed  and  rendered  as  aseptic  as  possible.  Then  a  loose 
substance,  usually  a  pledget  of  cotton,  was  placed  in  the  cavity  of  the 
tooth  and  the  case  dismissed  until  the  next  day.  This  treatment 
was  followed  daily  for  at  least  eight  or  ten  days  before  it  was  thought 
safe  to  fill  the  canals  and  tooth,  and  the  filling-operation  even  then 
was  completed  with  many  misgivings,  as  it  was  a  common  observa- 
tion that  quite  a  profuse  discharge  of  pus  would  follow  the  removal 
of  the  cotton  each  time  it  was  taken  from  the  tooth.  Periosteal  irri- 
tation frequently  followed  the  operation  of  filling,  often  so  severe  as 
to  result  in  an  abscess  in  spite  of  all  efforts  to  prevent  it. 

In  the  treatment  at  that  time,  the  antiseptics  used  were  a  solution 
of  carbolic  acid,  creasote,  listerine,  iodoform,  or  some  other  of  the 
then  favorite  remedies. 

Upon  the  introduction  of  bichlorid  of  mercury  as  an  agent  to 
destroy  organisms  and  the  products  of  putrefaction,  dental  surgeons 
at  once  found  in  it  the  long-sought-for  reliable  antiseptic  for  these 
cases.  It  was  at  first  used  in  too  strong  a  solution,  so  that  there  was 
more  or  less  danger  of  mercurially  poisoning  the  patient  in  case  it 
came  in  contact  with  the  mucous  membrane,  or  with  living  tissue  at 
the  apex.  It  was  soon  found,  however,  that  a  solution  so  weak  that 
it  could  do  no  harm  in  such  contingencies  was  equally  effective  as  an 
antiseptic.  This  led  to  a  more  liberal  irrigation  of  the  canals  than 
was  previously  practiced. 

The  solution  now  used  by  the  writer,  and  which  has  proved  so 
successful,  is  r -10,000  (one  grain  of  bichlorid  of  mercury  to  twenty 
ounces  of  water).     After  the  contents  of  the  canals  have  been  broken 


120 


DENTAL    PATHOLOGY   AND    PRACTICE. 


Fig. 


Up  by  the  use  of  a  fine  broach,  one  that  passes  into  and  through  the 
length  of  the  canals  easily,  the  solution  is  thrown  into  them  by  means 
of  a  fine  gold-pointed  syringe.  This  irrigation  is  repeated  until  the 
liquid  as  it  comes  out  upon  a  clean  white  napkin  produces  no  stain. 
The  canals  are  then  at  once    filled  without   drying  them    02d ;    the 

cement  used  taking  up  the 
^■^"  liquid   in  the  canal,    and 

the  mass  crystallizing  as 
a  whole. 

The  treatment  just  de- 
scribed is  followed  in  pref- 
erence to  the  protracted 
method  formerly  in  use, 
in  order  that  the  gases 
generated  by  the  decom- 
position of  the  contents  of 
the  canaliculi,  and  which 
find  exit  from  them  into 
the  pulp-canal  when  open, 
may  be  at  once  cut  off. 
When    the    canal    is   not 


filled,  or  when  it  is  imperfectly  filled,  these  gases  pro- 
duce both  a  mechanical  and  a  chemical  irritation  at  the 
apex  of  the  root.  The  crown  end  of  the  pulp-canal 
being  closed,  the  only  escape  for  the  gases  is  through 
the  apical  foramen.  It  is  through  this  double  irrita- 
tion that  pus  is  formed  and  fills  the  canal,  as  is  found 
so  frequently  when  teeth  are  being  ' '  treated' '  for  days, 
weeks,  and  sometimes  for  months. 

The  filling-material  used  in  pulpless  teeth  is  oxy- 
chlorid  of  zinc,  to  which  is  added  one  drop  of  a 
solution  of  bichlorid  1-2000.  The  bichlorid  is  incor- 
porated to  emphasize  the  aseptic  condition,  and  to 
make  sure  of  its  permanent  presence  in  the  canal. 
The  permanent  filling  in  the  tooth  is  made  at  once. 
Until  within  the  last  two  years,  if  any  periosteal  irri- 
tation existed,  the  filling  of  the  canals  and  crown 
was  postponed  until  the  irritation  had  subsided.  Concluding  that 
this  was  not  sound  practice,  for  the  reasons  above  stated,  the  teeth 
coming  under  treatment  in  this  condition  were  at  once  filled  the  same 
as  though  no  periostitis  existed.  As  a  therapeutic  measure  this  was 
believed  to  be  the  proper  course  to  pursue,  and  the  results  have 
proven  the  correctness  of  the  conclusion.  After  the  work  upon  the 
tooth  is  finished,  a  powerful  counter-irritant  is  applied  to  the  gum  over 


Pulpless  Tooth 
Syringe. 


ALVEOLAR   ABSCESS.  121 

the  root.  This  is  usually  "Antiphlogistin,"  a  mixture  of  equal  parts 
of  concentrated  tincture  of  aconite  root  and  tincture  of  iodin.  Other 
counter-irritants,  as  capsicum  plasters  or  cantharidal  collodion,  may  be 
used  ;  but  for  convenience  in  handling,  and  because  of  its  paralyzing 
effect  upon  the  vaso-motor  nerves,  aconite  seems  to  be  the  remedy 
required.  This  property  of  the  aconite,  together  with  the  lymphatic 
stimulation  of  the  iodin,  readily  diverts  the  blood-current  from  the  irri- 
tated and  engorged  periosteum  to  the  surface  of  the  gum,  and  relief 
soon  follows.  When  first  applied,  however,  if  the  periostitis  is  quite 
severe,  a  sensation  of  pressure,  or  fullness,  and  increased  pain 
follows,  lasting  sometimes  for  an  hour,  after  which  these  sensations 
subside  and  the  parts  become  greatly  relieved.  In  severe  cases  of 
periostitis,  the  mixture  may  be  applied  every  three  hours  without 
harm.  If  this  treatment  is  resorted  to  before  suppuration  at  the  end 
of  the  root  takes  place,  relief  invariably  follows.  The  application  of 
leeches  to  the  gum  over  the  tooth  is  productive  of  great  and  almost 
immediate  relief  in  many  cases. 

The  penetration  of  the  bichlorid  solution,  and  the  chlorid  of  zinc, 
into  the  canaliculi  is  of  great  importance  in  the  treatment  of  pulp- 
less  teeth,  as  it  changes  the  character  of  their  contents  into  a  condi- 
tion which  almost  precludes  the  possibility  of  further  decomposition. 
If  the  pulp  has  been  recently  removed,  coagulation  of  the  contents 
of  the  canaliculi  takes  place.  If  it  has  been  dead  for  a  period  long 
enough  for  putrefaction  to  have  occurred,  the  contents  become  satur- 
ated with  the  drugs,  putrefaction  ceases,  and  the  parts  remain  there- 
after in  an  aseptic  condition.  This  is  made  evident  when  on  opening 
a  pulp-canal,  treated  and  filled  in  the  manner  described,  and  drilling 
out  the  cement,  no  odor  of  putrefaction  is  discovered. 

Experiments  recently  conducted  by  Professor  James  Truman, 
D.D.S.,  have  fully  confirmed  me  in  the  opinion  I  have  long  held  as 
to  the  action  of  these  remedies  upon  the  contents  of  the  canaliculi  in 
pulpless  teeth. 


CHAPTER    XII  I. 

ALVEOLAR    ABSCESS. 


Umoer  this  heading  I  propose  to  consider  all  abscesses  dependent 
upon  or  related  to  the  teeth,  except  those  of  the  antrum. 

There  are  abscesses  occurring  frequently  in  the  mouth,  which  ap- 
pear so  much  like  alveolar  abscesses  proper  both  in  their  situation 
and  in  the  pain  which  they  produce,  that  they  are  sometimes  very 
difficult  to  diagnosticate  from  true  alveolar  abscess.  This  variety  I 
have  designated  false  alveolar  abscess. 


122  DENTAL    PATHOLOGY    AND    PRACTICE. 

,  In  alveolar  abscess  of  the  true  variety  we  have  always,  to  produce 
it,  a  dead  pulp  in  a  tooth,  or  portions  of  it  left  from  imperfect  ex- 
tirpation, or  an  open  or  partially  open  pulp-canal,  in  which  the  gases 
generated  by  putrefaction  of  the  organic  contents  of  the  canaliculi 
collect. 

The  death  of  the  pulp  of  a  tooth  may  be  caused  in  several  ways, 
the  most  common  of  which  is  its  exposure  to  debris  of  food,  acids, 
■etc.  (the  contents  of  a  carious  cavity),  by  the  progressive  destruction 
of  a  portion  of  the  crown  by  the  carious  process.  Under  such  cir- 
cumstances the  pulp  becomes  irritated,  which  condition,  unless 
relieved,  soon  passes  to  the  inflammatory  stage.  As  soon  as  the 
entire  pulp  becomes  congested  the  blood-vessels  cease  to  perform 
their  functions,  nourishment  is  cut  off,  and  of  course  the  death  of  the 
part  is  a  matter  of  a  short  time. 

Death  of  a  pulp  may  be  caused  by  traumatism.  A  slight  blow 
upon  a  tooth  laterally  will  often  result  in  the  death  of  its  pulp,  as 
the  irritation  at  the  apex  of  the  root  caused  by  the  shock,  unless 
promptly  relieved,  soon  passes  to  the  stage  of  congestion,  which 
•closes  the  blood-vessels  at  the  minute  foramen,  and  circulation 
■ceases.  The  nourishment  of  the  pulp  being  thus  cut  off,  its  death  is 
the  almost  immediate  result. 

Again,  a  pulp  may  be  impinged  upon,  and  the  same  chain  of 
results  follow  in  regulating  teeth  ;  or  the  trouble  may  arise  from  too 
rapid  or  too  severe  wedging,  to  obtain  room  for  filling.  Again,  it 
may  result  through  the  encroachment  of  an  abscess  at  the  root  of  an 
adjoining  tooth,  or  from  progressive  accumulation  of  tartar. 

After  the  death  of  a  pulp,  decomposition  soon  sets  in.  Up  to  this 
point  the  pain  in  some  instances  may  be  slight,  in  others  very  severe, 
and  the  periosteum  around  the  root  may  be  engorged,  so  that  the 
nerves  ramifying  in  this  membrane  are  pressed  upon  to  the  extent  of 
producing  periostitis,  which  is  manifested  by  an  elongation  of  the 
tooth,  or  rather  by  a  slight  projection  of  the  tooth  from  its  socket, 
and  a  feeling  of  soreness  upon  percussion,  or  upon  closing  the  oppos- 
ing tooth  upon  it.  This  constantly  increasing  painful  condition  con- 
tinues for  several  days,  when  the  patient  usually  experiences  a  chill 
(rigor),  which  indicates  that  suppuration  has  taken  place.  The  peri- 
osteum covering  the  end  of  the  root  is  lifted  (detached)  from  the 
cementum,  forming  a  receptacle  for  the  minute  quantity  of  pus 
which  is  the  first  product  of  the  suppurative  process.  As  the  accu- 
mulation of  pus  increases  the  pain  becomes  more  and  more  intense, 
the  walls  of  the  alveolus  are  destroyed  by  being  pressed  upon  on  all 
sides  alike  until  they  are  perforated  at  the  weakest  or  thinnest  point. 
This  may  occur  immediately  by  the  side  of  the  root,  or  it  may  be  at 
some  distance  from  it,  the  alveolus  yielding  to  the  destructive  process 


ALVEOLAR   ABSCESS.  I  23 

more  readily  in  some  directions  than  in  others,  which  may  be  ac- 
counted for  through  the  fact  that  the  inner  portion  of  this  process  is  of 
a  cancellous  structure,  while  the  outer  portion  is  compact,  the  can- 
cellous yielding  or  being  destroyed  by  the  constantly  increasing 
quantity  of  pus. 

As  the  bone  is  pierced,  the  pus  flows  out  into  the  yielding  soft 
parts,  and  the  pain  for  a  time  ceases  altogether.  As  soon,  however, 
as  the  limit  of  their  pliancy  is  reached,  the  pain  again  returns,  and 
the  destruction  of  the  surrounding  soft  tissues  begins,  until  eventually 
the  weakest  point  will  give  way,  and  evacuation  of  the  contents  of 
the  abscess  takes  place.  The  point  at  which  this  occurs  may  be 
upon  the  gum  immediately  over  the  tooth  affected,  or  it  may  be  far 
removed  from  it.  If  an  upper  tooth,  the  discharge  usually  takes 
place  very  near  its  origin  ;  if  the  upper  first  or  second  molar  is  affected, 
perhaps  the  antrum  may  receive  the  discharge.  Sometimes,  how- 
ever, pus  from  abscesses  of  other  upper  teeth  finds  its  way  to  very 
remote  regions  of  the  face.  For  instance,  some  years  ago  I  was 
called  to  see  a  gentleman  suffering  from  a  severe  abscess  resulting 
from  the  death  of  the  pulp  of  a  right  upper  lateral.  I  found  an 
opening  from  which  pus  discharged  upon  the  labial  portion  of  the 
gum,  another  upon  the  palatal  portion,  and  a  swelling  in  the  roof  of 
the  mouth  about  the  size  of  half  of  a  small  hen's  egg,  which,  upon 
a  careful  examination,  was  discovered  to  be  pointing  in  the  uvula. 
This  was  lanced,  and  the  evacuation  of  the  sac  in  the  roof  of  the 
mouth  was  the  result.  Persistent  efforts  to  cure  this  complicated 
condition  utterly  failed  until  the  tooth  was  removed,  when  I  found 
that  seme  dentist  in  attempting  to  dri//  out  the  pulp-canal  had  run 
the  drill  through  the  labial  portion  of  the  tooth  about  a  quarter  of  an 
inch  from  its  apex.  A  probe  could  be  readily  passed  back  inside  the 
teeth  on  that  side  to  and  into  the  antrum  in  one  direction,  and  to  the 
uvula  in  another. 

An  alveolar  abscess  in  the  lower  jaw,  if  occasioned  by  a  pulpless 
bicuspid,  first  or  second  molar,  is  likely  to  discharge  nearly  opposite 
the  tooth  affected.  When  a  lower  third  molar  is  the  offending  tooth,  the 
complications  are  greatly  increased.  The  alveolus  is  usually  thinnest 
toward  the  pharynx,  consequently  it  is  often  perforated  in  that  direction 
first.  When  the  soft  parts  in  this  locality,  which  yield  readily  to  the 
pressure  from  within,  are  loaded  with  an  increasing  quantity  of  pus,  the 
swelling  soon  enlarges  to  an  extent  that  places  the  patient  in  immi- 
nent danger  of  suffocation,  unless  speedy  relief  is  offered.  I  have 
known  of  several  cases  where  death  has  seemed  to  have  been  the 
result  of  such  abscesses.  In  my  own  practice  I  have  seen  and  had 
the  care  (after  the  trouble  had  occurred)  of  a  patient,  in  whose  case 
there  were  points  of  discharge  of  pus  in  several  places  on  the  side  of 


124  DENTAL    PATHOLOGY   AND    PRACTICE. 

the  neck,  distributed  from  near  the  angle  of  the  jaw  to  near  the 
clavicle,  in  all  some  three  or  four  fistulous  openings.  In  others,  the 
parotid  gland  and  subjacent  tissue  were  involved.  This,  in  my  judg- 
ment, is  the  most  dangerous  tooth  in  the  mouth  to  deal  with,  after 
the  death  of  its  pulp.  It  should  be  removed  as  soon  as  a  persistent 
tendency  to  suppuration  is  manifested.  The  narrow,  and  often  multiple 
canals,  and  their  tortuous  course,  render  it  impossible  to  cleanse  and 
fill  them  thoroughly.  This  tooth  is  consequently  more  liable  to 
periosteal  irritation  than  the  others,  which,  with  the  thicker  alveolus 
and  soft  parts  surrounding  it,  makes  it  almost  impossible  to  relieve 
any  disturbance  after  filling,  by  counter-irritants. 

An  abscess  from  any  one  of  the  six  lower  front  teeth  frequently 
finds  an  exit  for  pus  under  the  chin.  In  fact,  gravitation  has  much 
to  do  with  the  place  of  discharge  of  pus  from  an  abscess  caused  by 
the  death  of  the  pulp  in  any  lower  tooth. 

A  false  abscess  is  one  produced  in  the  gum-tissue  overlapping  or 
resting  against  the  rough  surface  of  tartar  in  cases  of  pyorrhea.  It 
is  what  might  aptly  be  called  a  "gum-boil."  It  is  a  circumscribed 
cellulitis,  resulting  in  suppuration. 

Differential  Diagnosis. — In  true  alveolar  abscess,  the  affected  tooth 
will  usually  be  more  or  less  darker  than  normal,  and  the  gum  around 
it  will  be  found  mostly  in  a  healthy  condition  and  firmly  attached  to 
the  neck  of  the  tooth,  while  in  the  false  variety  the  tooth  will  be 
found  of  its  natural  color,  the  gum  over  it  highly  congested  and 
detached  from  the  root,  upon  which  will  be  found  a  deposit  of  rough 
black  or  dark  brown  tartar,  extending  to,  and  perhaps  considerably 
beyond,  the  point  where  cellulitis  set  in. 

The  prognosis  in  most  cases  of  true  alveolar  abscess  is  favorable 
for  the  preservation  of  the  tooth  and  the  cure  of  the  abscess.  The 
exceptions  are  in  cases  where  the  antrum  becomes  involved,  or  necro- 
sis of  the  surrounding  alveolus  takes  place  sufficiently  to  invoh^e  the 
greater  portion  of  the  socket  of  the  tooth. 

In  the  upper  jaw  the  prognosis  is  more  favorable  for  the  cure  of 
the  disease  than  in  the  lower,  from  the  fact  that  in  the  lower,  the 
foramen  in  the  end  of  the  root  or  roots  is  a  depending  opening 
through  which  any  portion  of  the  dead  pulp  left,  or  any  detached 
portion  of  the  filling-material,  is  liable  to  gravitate,  thus  keeping  up 
a  constant  irritation.  Again,  the  anterior  roots  of  lower  molars  are 
often  tortuous,  having  in  most  cases  two  narrow  canals,  which  are 
most  difficult  to  thoroughly  cleanse. 

Treatment. — ^In  the  great  majority  of  cases,  the  successful  treat- 
ment of  an  alveolar  abscess  is  one  of  the  simplest  operations  we 
have  in  dental  surgery.  It  consists,  first,  in  evacuating  the  sac  as 
soon  as  fluctuation   can   be  detected.      For  this  purpose  a  four  per 


ALVEOLAR    ABSCESS.  I  25 

cent,  solution  of  muriate  of  cocain  is  applied  to  the  surface  through 
which  it  is  proposed  to  pierce.  After  about  five  minutes,  a  curved- 
pointed  bistoury  is  forced  through  into  the  pus-sac,  which  will  then  soon 
empty  itself  In  a  few  days  the  parts  will  have  assumed  their  normal 
condition,  except  the  opening  in  the  gum,  through  which  a  constant 
discharge  of  pus  is  taking  place. 

The  tooth-crown  should  now  be  drilled  through  to  the  pulp-chamber, 
as  directly  as  possible  on  a  line  with  the  root- canals  ;  this  may  be 
done  with  a  drill  not  more  than  one-sixteenth  of  an  inch  in  diameter. 
The  dentine  immediately  over  the  pulp-chamber  should  be  cut  away 
until  every  portion  of  the  chamber  can  be  reached  and  thoroughly 
cleansed.  Should  an  unpleasant  odor  come  from  the  putrefying  pulp, 
a  solution  of  three  grains  of  permanganate  of  potash  to  one  ounce  of 
water  may  be  thrown  into  the  opening  as  a  deodorizer,  to  be  repeated 
as  often  as  the  disagreeable  odor  returns. 

The  contents  of  the  canals  are  next  removed.  This  is  best  done, 
in  case  disintegration  of  the  pulp  has  occurred,  by  stirring  the  mass 
briskly  with  a  broach,  and  then  with  a  fine-pointed  metallic  syringe 
throwing  into  the  canal  or  canals  a  solution  of  i-io,ooo  bichlorid  of 
mercury.  This  irrigation  is  repeated  several  times  in  each  canal,  a 
napkin  being  held  in  the  mouth  to  catch  the  liquid  as  it  issues  from 
the  parts.  When  the  napkin  is  no  longer  stained  by  the  discharge, 
it  is  safe  to  conclude  that  the  dead  and  putrefied  pulp  has  all  been 
removed.  In  most  cases  the  solution  thus  forced  into  the  canal  will 
pass  through  it,  into  and  through  the  abscess,  and  out  upon  the 
gum.  We  have  now  an  emphatically  aseptic  condition  of  the  pulp- 
chamber,  canal,  and  abscess.  Not  only  are  the  organisms  of  decom- 
position destroyed,  but  the  products  (ptomaines)  are  washed  out  of 
the  canal,  or  rendered  inert. 

The  next  step  in  the  operation  is  to  destroy  the  abscess-sac,  which 
is  done  by  means  of  an  escharotic.  The  best  agent  for  this  purpose, 
and  that  which  is  the  least  objectionable,  in  my  judgment,  is  zinc 
chlorid,  which  is  used  in  solutions  of  four  different  strengths, — one 
of  ten  grains,  one  of  twenty  grains,  one  of  forty  grains,  and  one  of 
sixty  grains,  to  one  ounce  of  water.  Satisfactory  results  are  obtained 
with  adult  patients,  where  the  abscess  is  of  recent  origin,  with  the 
twenty-grain  solution.  The  weaker  solution  may  be  used  in  the 
case  of  children.  If  a  chronic  condition  exists  in  adults,  the  forty- 
grain  solution  is  used  ;  while  if  the  abscess  be  a  very  old  and  obstinate 
one,  the  sixty-grain  solution  is  used.  This  is  forced  through  the 
canal  Avith  a  syringe  or  by  means  of  a  bit  of  cotton  wound  upon  a 
broach,  which,  after  saturation  with  the  solution,  is  forced  back 
and  forth  in  the  canal  until  the  drug  appears  upon  the  gum.  Should 
either  of  these  methods  be  impracticable  in  consequence  of  the  small, 


126  DENTAL    PATHOLOGY    AND    PRACTICE. 

tortuous,  or  narrow  caliber  of  the  canals,  as  is  frequently  the  case  in 
upper  first  bicuspids,  in  all  of  the  upper  molars,  and  in  anterior 
roots  of  lower  molars,  then  a  piece  of  cotton,  loosely  rolled,  is  sat- 
urated with  the  solution,  placed  in  the  crown  cavity,  and  a  bit  of 
slightly  softened  wax  or  a  softened  piece  of  gutta-percha  is  placed 
in  the  orifice,  and  with  a  broad-pointed  instrument  forced  against 
the  cotton,  gently  at  first,  and  at  last  somewhat  vigorously,  so  that 
all  the  liquid  is  pressed  out  of  it  into  the  canals.  After  repeating 
this  several  times,  the  solution  will  usually  be  seen  bubbling  out  of 
the  opening  in  the  gum.  The  roots  and  cavity  in  the  tooth  are  at 
once  filled,  no  attempt  being  made  to  dry  the  canals.  There  are 
several  reasons  for  this  course.  First,  the  immediate  filling  of  them 
prevents  the  former  septic  condition  from  returning,  which  is  sure  to 
occur  if  the  canal  is  left  open,  in  consequence  of  the  continued  putre- 
faction of  the  contents  of  the  canaliculi,  the  result  of  which  finds  its 
way  through  the  thousand  and  one  openings  into  the  pulp-canal ; 
second,  if  the  canals  are  dried  out  the  former  septic  condition  is  liable 
to  return  at  once. 

The  filling-material  which  offers  to  me  the  least  objections,  and  the 
one,  too,  which  accomplishes  the  work  most  satisfactorily,  is  oxy- 
chlorid  of  zinc,  with  one  drop  of  a  solution  of  bichlorid  of  mercury 
(i-2ooo)  added  to  each  mixture.  This  emphasizes  the  antiseptic 
condition,  and  seals  the  canal  from  the  apex  to  the  pulp-chamber. 

The  cavity  in  the  crown  is  at  once  filled,  in  order  that  all  irritation 
to  the  tooth  or  periosteum  may  cease,  and  the  abscess  be  allowed  to 
heal.  Should  the  filling  of  the  tooth  be  postponed  for  a  length  of 
time  after  the  fistulous  opening  has  healed,  the  disturbance  set  up  by 
the  operation  (which  is  usually  a  long  one)  will  possibly  cause  a 
recurrence  of  the  trouble. 

The  question  might  here  be  asked,  How  are  the  canals  filled  with 
the  cement  where  it  is  quite  impracticable  to  explore  them  with  the 
finest  instrument?  In  such  cases,  the  cavity  in  the  crown  is  filled 
with  the  thin  oxychlorid,  and  a  piece  of  softened  gutta-percha  is 
carefully  but  firmly  pressed  into  the  cavity,  forcing  the  cement  into 
the  remotest  portion  of  the  canal. 

After  a  lapse  of  about  two  weeks,  if  it  is  found  that  pus  still  dis- 
charges from  the  opening  upon  the  gum,  a  solution  of  i-io,ogo  bi- 
chlorid of  mercury  is  pumped  through  it  into  the  abscess  by  means 
of  a  fine-pointed  metal  syringe,  until  it  is  cleansed.  Then  an  appli- 
cation is  made,  in  the  same  manner,  of  the  solution  of  forty  grains 
of  zinc  chlorid  to  one  ounce  of  water.  It  is  seldom  that  more  than 
one  application  is  necessary  to  effect  a  cure. 

The  treatment  oi  false  alveolar  abscess  consists  in  evacuating  the 
sac,  and  cleansing  the  root  of  all  foreign  matter. 


DISEASES    OF   THE   ANTRUM.  I27 


CHAPTER   XIV. 

DISEASES   OF   THE  ANTRUM   DUE  TO   DENTAL   COMPLICATIONS, 
AND    THEIR   TREATMENT.« 

Antrum  is  a  name  given  to  certain  cavities  in  bones,  the  openings 
into  which  are  smaller  than  the  cavities  themselves.  The  antrum  of 
Highmore  was  known  in  Galen's  time,  but  it  was  not  until  1651  that 
a  rational  description  of  it  was  given  by  Nathaniel  Highmore,  of 
Sherburne,  England.  It  is  a  deep  cavity  in  the  substance  of  the 
superior  maxillary  bone,  communicating  with  the  middle  meatus  of 
the  nose  by  an  opening  (in  the  recent  state)  about  the  size  of  an 
ordinary  knitting-needle,  through  which  the  Schneiderian  membrane 
is  prolonged  to  line  the  cavity.  It  is  called  by  anatomists  an  irregu- 
lar triangular-shaped  cavity.  Its  floor  is  formed  by  the  alveolar  pro- 
cess, and  its  roof  by  the  floor  of  the  orbit.  Any  further  anatomical 
description  of  this  cavity,  at  this  time,  would  be  superfluous,  except 
in  a  few  respects,  which  bear  more  directly  upon  the  subject  before 
us.  The  bony  covering  of  the  antrum  is  extremely  thin  in  several 
places  ;  so  much  so,  that  pressure  brought  upon  it  by  excessive  accu- 
mulations in  the  cavity  causes  it  to  bulge  perceptibly,  and  unless  it  is 
early  evacuated  perforation  of  these  thin  walls  ensues.  These  locali- 
ties are — (i)  immediately  above  the  canine  fossa  ;  (2)  upon  the  buccal 
wall,  above  and  between  the  roots  of  the  first  and  second  molars  ;  (3) 
above  and  between  the  palatal  roots  of  these  molars  ;  (4)  the  orbital 
floor. 

A  feature  of  no  little  interest  and  importance  in  studying  the 
antrum,  especially  pathologically,  is  the  variation  in  its  situation.  It 
has  been  said  that  in  the  examination  of  one  hundred  skulls,  no  two 
presented  this  cavity  in  precisely  the  same  situation.  Some  are  large, 
some  small,  some  are  much  higher  than  others,  some  well  to  the 
front,  others  are  set  deep  back,  and  in  many  instances  the  location 
of  the  two  sides  is  very  different  in  the  same  face,  one  side  being  very 
large,  prominent,  and  high,  while  the  other  is  the  reverse. 

If  the  face  be  short  and  broad,  the  indications  are  that  the  floor  of 
the  antrum  is  penetrated,  or  nearly  so,  by  the  roots  of  the  first  and 
second  molars,  and  perhaps  by  that  of  the  second  bicuspid  as  well. 
So  far  as  my  observation  has  gone,  the  first  bicuspid  and  cuspid 
seldom,  if  ever,  penetrate  the  floor  of  this  cavity  with  their  roots. 

Physiology  or  Function. — The  antrum,  like  the  frontal  sinuses,  being 
connected  with  and  forming  a  part  of  the  air-passages,  is  made  use  of  as 
a  reservoir  for  air,  which  is  kept  at  the  temperature  of  the  body  ;  and 

*  Abbott,  Dental  Cosmos,  1889. 


128  DENTAL   PATHOLOGY   AND    PRACTICE. 

in  the  act  of  inhalation  this  warm  air  becomes  mixed  with  the  cold, 
so  that  upon  its  entrance  into  the  lungs  it  is  slightly  tempered. 
Again,  as  the  cavity  is  lined  with  Schneiderian  membrane,  it  undoubt- 
edly serves  to  a  limited  extent  to  assist  in  the  delights  or  Otherwise 
attendant  upon  the  use  of  the  special  sense  of  the  nasal  organ. 

Diseases. — It  is  an  undoubted  fact  that  the  great  majority  of  the 
cases  of  disease  of  the  antrum  are  due  directly  to  dental  complica- 
tions. Other  diseases  of  the  antrum,  such  as  the  different  varieties  of 
tumors  and  the  "troubles  common  to  mucous  membrane  wherever 
situated,"  occur  so  rarely  as  compared  with  that  for  which  the  dental 
organs  are  especially  responsible,  that  I  am  disposed  to  confine  my- 
self to  the  consideration  of  that  alone. 

It  has  been  stated  that  it  is  a  misnomer  to  call  this  disease  abscess 
of  the  antrum,  from  the  fact  that  but  for  the  close  proximity  of  dis- 
eased teeth  such  a  disturbance  would  probably  not  take  place. 
Recognizing  the  force  of  this  argument,  would  it  not  be  well  to  speak 
of  it  as  an  alveolar  abscess,  the  pus  from  which  finds  exit  into  and 
through  the  antrum  ?  By  the  presence  of  the  pus,  however,  the 
entire  mucous  membrane  lining  the  antral  cavity  often  becomes  in- 
flamed and  more  or  less  hypertrophied,  so  that  if  of  long  standing  a 
quite  general  ulceration  takes  place,  and  in  some  rare  instances  the 
soft  tissue  covering  the  bone  is  altogether  destroyed  in  places,  leaving 
the  bone  bare.  Thus  it  becomes  a  disease  of  the  mucous  membrane 
lining  the  cavity  itself;  and  for  these  reasons  it  has  received  the  name 
of  abscess  of  the  antrum.  Abscesses  in  this  cavity  are  spoken  of  as 
arising  from  mal-positioned  teeth.  Undoubtedly  this  might  be  the 
case,  but  it  has  never  been  my  privilege  to  see  one. 

Diagnosis. — The  means  of  diagnosing  an  abscess  of  the  antrum  are 
quite  numerous,  and  generally  conclusive.  The  first  symptom  of  a 
disturbance  which  results  in  such  a  disease  is  a  slight  soreness  of  a 
tooth  the  pulp  of  which  is  lifeless  ;  then  follows  a  dull,  heavy  pain 
(sometimes  sharp  and  darting  up  the  side  of  the  head)  in  that  side 
•of  the  face.  This  increases  moderately  in  severity,  for  days,  weeks, 
and  sometimes  for  months,  before  any  very  especial  notice  is  taken  of 
it  by  the  patient,  when  attention  is  directed  to  it  more  particularly  by 
a  decidedly  heavy  feeling  and  increased  pain  in  the  cheek  upon  bend- 
ing forward,  or  in  tipping  the  head  from  side  to  side.  If  the  cavity 
becomes  considerably  filled  with  pus  before  the  lining  membrane  be- 
comes sufficiently  inflamed  and  thickened  to  have  closed  the  opening 
into  the  nose,  an  excessive  discharge  will  be  noticed  from  that  organ 
upon  the  affected  side.  This  discovery  usually  takes  the  patient  to 
the  family  physician,  who  at  once  pronounces  the  disease  catarrh  or 
ozena,  and  proceeds  in  his  treatment.  This  often  continues  for 
months,  and  perhaps  for  years,  before  the  real  difficulty  is  ascertained. 


DISEASES    OF   THE   ANTRUM.  129 

Should  the  lining  membrane  become  inflamed  and  thickened 
sufficiently  to  close  the  opening  into  the  nose,  the  cavity  then  be- 
comes filled  with  pus,  and  in  consequence  of  its  continued  augmen- 
tation pressure  begins  around  the  surrounding  walls.  The  inflam- 
mation, together  with  the  pressure,  causes  absorption,  or  a  melting 
down  of  the  walls  progressively  until  an  exit  for  the  pent-up  pus  is 
effected,  unless  surgical  relief  is  obtained.  While  this  progress- 
ive destruction  of  the  bony  wall  is  going  on,  a  decided  bulging  of  it 
takes  place  in  the  localities  above  referred  to.  A  prominence  is 
observed  by  the  side  of  the  nose,  over  the  molar  teeth,  and  in  the 
mouth  upon  that  side,  w'hile  the  orbit  is  pushed  up  and  out  to  such 
an  extent  that  the  affected  eye  is  considerably  elevated  above  the 
other.  By  pressing  with  the  thumb  upon  the  prominence,  by  the 
side  of  the  nose  particularly,  crepitation  may  be  heard  very  dis- 
tinctly. With  the  above  diagnostic  signs  presenting,  it  is  generally 
safe  to  conclude  that  an  abscess  involving  the  antrum  is  the  disease 
to  be  combated. 

Differential  Diagnosis. — In  order  to  differentiate  between  catarrh, 
or  ozena,  and  antral  abscess,  it  should  first  be  ascertained  whether 
there  are  any  pulpless  teeth  in  that  side  of  the  upper  jaw,  and  a 
careful  observation  should  be  made  as  to  the  relative  situation,  of  the 
antrum.  If  pulpless  teeth  are  found,  and  the  face  is  short  from  the 
oral  cavity  to  the  orbit,  the  indications  are  strongly  in  favor  of  an 
abscess  in  the  cavity  of  the  antrum,  even  should  no  other  especial 
diagnostic  sign  be  present  except  the  discharge  from  the  nose.  On 
the  other  hand,  should  no  pulpless  teeth  be  found,  or,  when  present, 
if  the  face  be  long  between  the  orbit  and  oral  cavity,  indicating  that 
the  alveolar  process  is  very  thick  between  the  floor  of  the  antrum  and 
the  roots  of  the  teeth,  it  would  indicate  that  no  abscess  in  the 
antrum  existed.  The  absence  of  pulpless  teeth  would  make  the 
evidence  more  conclusive. 

Prognosis. — The  prognosis  in  the  majority  of  cases  is  favorable, 
and  with  careful  treatment  they  will,  within  from  three  weeks  to  as 
many  months,  be  entirely  cured.  There  are  conditions,  however, 
which  militate  against  a  successful  termination  of  the  best  directed 
efforts.  These  are,  in  both  sexes,  in  patients  of  advanced  age,  with 
a  generally  low  physical  condition  ;  those  of  sedentary  habits,  poor 
digestion  ;  and  those  suffering  from  chronic  malarial  poison  or  from 
some  specific  disease.  In  the  female  the  period  of  cessation  of  the 
menses  (change  of  life)  is  probably  the  most  troublesome  to  combat 
the  diseases  of  this  cavity. 

Dr.  J.  L.  Mewborn,  of  Memphis,  Tenn. ,  who  has  devoted  much 
time  to  the  study  of  these  cases,  has  arrived  at  the  conclusion  that 
abscess   from   any  cause   located   in  the  cavity  of  the  antrum  of  a 


130  DENTAL    PATHOLOGY   AND    PRACTICE. 

female,  at  or  beyond  ^the  "climacteric  period,"  is  seldom  if  ever 
permanently  cured.  From  his  report  of  cases,  I  do  not  feel  disposed 
to  deny  his  position.  However,  the  first  case  I  ever  treated  was  in 
the  mouth  of  a  lady,  the  patient  being  over  fifty  years  of  age.  In  the 
course  of  a  month  all  discharge  stopped,  and  the  opening  healed.  I 
saw  the  lady  frequently,  and  for  some  three  years  she  had  no  pain  or 
uneasiness  to  indicate  that  all  was  not  well  in  that  antrum.  Finally, 
after  about  three  and  a  half  years,  an  abscess  made  its  appearance 
again,  accompanied  by  all  the  pains  and  generally  disagreeable 
features  attending  the  formation  of  the  original  one.  Upon  ex- 
amination I  found  a  second  bicuspid,  which  had  been  pulpless  for 
many  years,  to  be  the  exciting  cause.  This  I  at  once  removed, 
cleansed  the  antrum,  and  treated  it  a  few  times,  when  the  lady  left  the 
city  ;  and  I  have  never  seen  her  since.  This  was  some  eight  or  ten 
years  ago.  She  is  alive,  however,  and  so  far  as  I  know  she  recovered 
from  her  antrum  trouble  the  second  time  as  promptly  as  she  did  the 
first ;  but  on  the  other  hand  she  may  never  have  recovered,  and  this 
may  be  one  of  the  cases  which  would  go  to  prove  Dr.  Mewborn's 
position. 

In  another  case,  which  I  saw  first  in  consultation  some  three  years 
ago,  the  patient  being,  I  should  judge,  some  forty-eight  or  fifty 
years  of  age,  I  made  a  careful  examination  of  the  antral  cavity,  and 
could  find  no  necrosed  bone,  nor  any  condition  that  would  pre- 
clude the  possibility  of  a  cure  within  a  few  weeks,  or  months  at  most. 
I  did  not  see  her  again  for  two  years,  when  she  was  brought 
to  me  by  another  practitioner.  I  then  made  another  careful  ex- 
amination of  her  antrum,  and  found  a  territory  of  denuded  bone, 
as  large  (as  nearly  as  I  could  judge)  as  a  five-cent  silver  piece, 
located  at  the  upper  posterior  wall  of  the  cavity.  I  advised  as  to 
treatment,  and  the  patient  went  away.  I  have  since,  by  request,  ex- 
amined this  case,  and  now  believe  the  bone  that  was  bare  when  I 
saw  her  eight  months  ago  has  been  re-covered  with  the  lining  mem- 
brane of  the  cavity.  The  opening  into  the  antrum  from  the  oral 
cavity  remains  about  the  same  ;  it  is  extremely  small,  however.  One 
peculiar  feature  presented  itself  in  connection  with  this  case,  which 
may  be  of  interest,  if  not  of  use,  to  some  who  may  read  this.  The 
lady  complained  of  intense  darting  pains  in  that  side  of  the  face,  either 
in  or  immediately  under  the  skin.  For  some  time  I  was  unable  to 
account  for  these,  but  finally  it  dawned  upon  me  that  probably  the 
denuded  and  constantly  irritated  bone  in  the  antrum  was  in  contact 
with  the  infra-orbital  nerve,  or  perhaps  formed  a  portion  of  its  im- 
mediate covering,  so  that  the  trunk  of  the  nerve  received  the  injury 
which  manifested  itself  at  its  terminal  fibers  upon  the  face.  The 
treatment  was   consequently  directed  to  allay  the  irritation  of  the 


^ 


DISEASES   OF   THE   ANTRUM. 


131 


trunk  of  the  nerve,  which  gave  relief.     This  is  another  case  which 
might  be  cited  to  sustain  Dr.  Mewborn's  position,  as  I  beheve  now, 

after  these  years,  a  great  portion 
^^'  ^^'  of  the   time   under  treatment  by 

different  dentists,  it  is  still  open. 
There  appears  to  be  no  discharge 
of  pus  from  it,  however. 

Treatment. — The  treatment  con- 
sists in  first  obtaining  a  sufficiently 
large,  depending  opening  into  the 
antrum  to  admit  of  its  thorough 
exploration,  the  ready  application 
of  remedies,   and   its  involuntary 
evacuation  of  all  fluid  substances. 
This  is  accomplished  by,  first,  the 
removal   of  the   offending  tooth. 
This  I  know  will  be  objected  to  by 
some,  but  I  consider  it  as  a  rule  by 
far  the  safest   procedure.      If  the  tooth  so  re- 
moved be  the  first  or  second  molar,  a  sharp  bur 
of  the  size  it  is  desired  the  opening  should  be  is 
driven  with  an  engine  through   the  socket  of 
the     anterior    buccal     root     into   the    antrum, 
cutting   all   intervening    bone   as    it   proceeds  ; 
then    with   lukewarm  salt   water  the  cavity   is 
thoroughly  washed  out,  a  spray  syringe  being 
used  for  the  purpose,     A  most  searching  explor- 
ation of  the  cavity  is  now  made  with  a  probe, 
to  ascertain  whether  any  necrosis  of  the  bony 
wall  is  present.     If  found,  it  should  be  removed. 
If  none  is  found  (as  it  seldom  is),  the  treatment 
is  proceeded  with  as  follows  :    Any  unpleasant 
odor  arising  from   it  can  be  controlled  by  the 
use  of  a  solution  of  permanganate  of  potash, 
two  grains  to  one  ounce  of  water.     This  is  not 
strong   enough   to    irritate   the   delicate   lining 
membrane  of  the  antrum,  but  it  will  very  effec- 
tually deodorize  it.     The  cavity  is  then  washed 
out  as  thoroughly  as  practicable  with  a  solution 
of  carbolic  acid  one  to  sixty-four.     This  again 
is  not  strong  enough  to  irritate  the  delicate  lining- 
membrane  of  the  cavity,  though  in  this  strength 

Spray  Antral  Syringe.     -^   -^  ^  ^^^^^   effective   antiseptic.       A   solution    of 

equal  parts  of  listerine  and  water  is  often  very  efficacious  as  an  anti- 


132 


DENTAL    PATHOLOGY   AND    PRACTICE. 


septic  in  the  treatment  of  these  cases  ;  a  saturated  solution  of  boracic 
acid  in  warm  water  is  also  of  excellent  service.  There  is  no  doubt 
of  the  efficacy  of  bichlorid  of  mercury  as  an  antiseptic.  I  have  tried 
it  but  once,  however,  when  I  used  a  solution  of  one  to  two  thousand. 
This  produced  so  much  irritation  that  I  have  since  confined  myself  to 
milder  applications.  I  have  no  doubt,  however,  that  a  preparation  of 
one  to  five  thousand  might  be  used  to  good  advantage.  One  feature 
which  especially  recommends  it  for  use  in  the  mouth  is  that  it  has  no 
disagreeable  taste  or  smell.  After  washing  the  cavity  with  any  one 
of  the  above  remedies,  I  apply  the  same  more  effectually  by  means 
of  the  spray  apparatus.     As  a  stimulant  I  use  tincture  of  iodin,  one 

Fig.  56. 


vN  3>  \tv^    K^\^ 


Antrum  Spray. 
To  be  used,  with  antiseptic  solutions,  in  cases  of  persistent  accumulation  of  pus  in  the  sinus. 

drachm  to  an  ounce  of  the  carbolic  acid  solution.  Here  I  wish  to 
remark  that  my  first  idea  of  the  use  of  a  spray,  as  a  more  perfect 
means  of  medicating  the  antrum,  was  obtained  from  Dr.  J.  L.  Mew- 
born,  of  Memphis,  in  1884.  He,  however,  uses  the  remedy  warm, 
and  applies  it  by  means  of  a  hand  atomizer  with  a  single  jet.  I  use 
compressed  air,  with  a  pressure  of  thirty  to  forty-five  pounds  to  the 
square  inch,  and  a  multiple  spray.  The  pressure  forces  the  remedy 
into  every  irregularity  of  mucous  membrane,  and  the  multiple  spray 
reaches  all  parts  of  the  cavity.  This  mode  of  applying  remedies  to 
the  cavity  of  the  antrum  I  consider  of  incalculable  service  in  the  suc- 
cessful treatment  of  many  cases,  and  I  cannot,  nor  do  I  think  the 
profession  in  general  can  thank  Dr.  Mewborn  enough  for  this  valuable 
addition  to  their  armamentarium  for  the  treatment  of  this  disease. 


DISEASES    OF    THE   ANTRUM,  I33 

After  thoroughly  medicating  as  above  described,  means  must  be 
taken  to  prevent  the  opening  from  closing  too  rapidly.  This  is  done 
by  means  of  cotton  wound  upon  a  roughened  bit  of  wood,  or  a  bit 
from  a  whisk  broom,  as  near  as  can  be  judged  the  size  of  the  open- 
ing. This  is  dipped  into  carbolized  oil  of  sweet  almonds  (one  part 
of  carbolic  acid  to  fifteen  of  the  oil),  then  placed  in  position,  and  tied 
with  silk  to  an  adjoining  tooth.  This  treatment  is  followed  up  every 
day,  and  as  soon  as  all  signs  of  pus  have  disappeared  the  plug  is  each 
day  made  smaller,  until  the  opening  is  closed  entirely.  I  never  use 
a  drainage-tube.  In  order  to  test  for  the  presence  of  pus,  peroxid  of 
hydrogen  may  sometimes  be  used  to  advantage. 

In  cases  where  from  the  history  it  is  evident  that  a  specific  poison 
has  to  be  combated,  iodid  of  potassium  is  given  in  five-grain  doses 
three  times  a  day,  and  each  day  the  dose  is  increased  one  grain  until 
the  patient  becomes  perceptibly  affected  by  it,  which  will  be  mani- 
fested by  a  decrease,  and  finally  a  cessation  of  the  discharge  of  pus. 
Many  cases  yield  readily  to  the  effect  of  sulfid  of  calcium,  given  in 
one-tenth  grain  doses  three  times  a  day. 

It  is  frequently  the  case  that  patients  are  anemic,  consequently 
the  disease  yields  slowly,  if  at  all,  to  local  treatment.  In  such  cases 
ammonio-citrate  of  iron,  in  from  five  to  ten-grain  doses,  three  times 
a  day,  is  found  of  excellent  service.  Quinin  sulfate  in  two-grain 
doses,  three  times  a  day,  is  found  useful.  Persons  who  take  very 
little  out-door  exercise,  especially  if  past  middle  age,  should  be  di- 
rected to  take  such  exercise  liberally  and  systematically  every  day. 

It  will  be  observed  that  I  have  spoken  of  but  one  means  of  gain- 
ing an  entrance  to  the  antrum.  Other  modes  are  adopted  by  some 
surgeons,  some  of  which  I  do  not  approve  of  Some  years  since, 
I  listened  to  the  description  of  an  operation  for  this  purpose,  and 
saw  the  patient  upon  whom  the  operation  had  been  performed.  It 
was  at  a  meeting  of  the  New  York  Odontological  Society.  The 
operation  consisted  in  making  an  incision  from  the  corner  of  the 
mouth  back  past  the  external  antral  wall,  dissecting  the  soft  tissues 
from  the  wall,  and  making  an  opening  into  the  antrum  over  the 
molar  teeth.  It  was  spoken  of  as  a  great  and  very  successful  opera- 
tion. This  may  have  been,  so  far  as  the  cure  of  the  disease  was  con- 
cerned ;  but  it  seems  to  me  that  the  means  adopted  were  alto- 
gether too  heroic  and  not  at  all  necessary.  Here  was,  from  the  history 
of  the  case,  a  simple  abscess  from  a  pulpless  tooth  emptying  into 
the  antrum,  which  would  have  been  treated,  and  probably  cured,  in 
a  few  weeks  by  a  competent  dental  surgeon,  with  no  surgical  work 
whatever  except  the  removal  of  the  offending  tooth  and  the  enlarging 
of  one  of  the  sockets.  In  my  judgment,  dental  surgeons  ought  to 
openly  discourage,  in  the  strongest  manner  possible,  such  uncalled- 


134  DENTAL    PATHOLOGY   AND   PRACTICE, 

for  surgical  work  as  was  shown  in  this  case.  Patients  suffer  quite 
enough  when  such  cases  are  treated  in  the  most  conservative  manner 
possible. 

A  most  interesting  and  instructive  case  came  under  my  observation 
some  years  ago.  A  gentleman  some  thirty-five  years  previously  had 
received  a  scratch  on  the  cheek,  by  the  left  side  of  the  nose,  which, 
despite  all  the  efforts  of  the  best-skilled  physicians  in  this  country 
and  Europe,  would  not  heal.  It  was  pronounced  a  rodent  ulcer,  or 
flat  cancer.  It  increased  in  size  and  annoyance  very  slowly  indeed, 
so  much  so  that  at  times  it  was  thought  to  be  more  or  less  under 
control.  Some  twenty  years  before  I  saw  him  professionally,,  he  had 
had  the  pulp  destroyed  in  the  left  upper  second  molar,  and  the  tooth 
filled  in  Paris.  Some  ten  years  after  this,  his  dentist  in  this  city  had 
refilled  the  cavity  in  the  crown  of  the  tooth,  but  had  done  nothing 
with  the  roots,  they  seeming  to  be  filled  satisfactorily,  as  no  trouble 
had  been  experienced  from  them.  While  summering  out  of  the 
city,  shortly  before  I  was  called  in,  the  face  on  that  side  commenced 
to  swell ;  the  eye  became  pushed  up  very  considerably,  causing 
severe  and  constant  pain.  Upon  examination,  I  concluded  that  the 
pulpless  molar  had  caused  an  abscess  in  the  antrum.  I  was  requested 
by  his  dentist  and  attending  physician  to  remove  the  tooth.  This  I 
did,  and  found  my  diagnosis  correct.  Immediately  upon  its  removal 
quite  a  quantity  of  black,  fetid  matter  was  discharged.  This  kept  up 
during  the  following  night  and  a  part  of  the  next  day.  Upon  prob- 
ing the  antrum,  it  was  found  nearly  filled  with  a  mass  which  proved 
to  be  cancerous.  From  this  time  forward  the  growth  of  the  cancer 
was  very  rapid.  In  a  few  months'  time  I  had  removed  all  the  teeth  in 
the  upper  jaw,  and  several  other  operations  had  been  performed, 
large  masses  of  the  growth  being  removed  to  prevent  suffocation. 
Death  finally  relieved  him  of  his  sufferings.  The  lesson  to  be  learned 
from  the  case  is  this  :  where  an  incurable  disease  is  present  upon  the 
face,  great  care  should  be  taken  that  the  dental  organs  are  not 
allowed  to  become  an  auxiliary  in  its  progress,  thus  increasing,  to  a 
great  extent,  the  sufferings  of  the  patient,  and,  in  consequence,  very 
considerably  shortening  his  life.  In  this  case  the  seat  of  the  disease 
was  apparently  changed  from  his  face,  outside,  to  the  antrum,  caused 
undoubtedly  by  this  pulpless  molar.  Its  more  rapid  development, 
and  consequent  increase  of  suffering  and  shortening  of  his  life,  was 
the  result. 


ABSCESSES    IN   THE   SALIVARY    GLANDS.  135 

CHAPTER   XV. 

ABSCESSES    IN   THE  SALIVARY   GLANDS.  ' 

Fortunately,  abscesses  in  the  salivary  glands  are  comparatively- 
rare.  Their  occurrence,  however,  is  frequent  enough  to  demand  a 
passing  notice.  The  recognized  causes  of  abscess  in  the  salivary 
glands  are  three  :  First,  and  the  most  common,  is  the  deposit  of  a 
calculus  ;  second,  external  injury  ;  and  third,  a  severe  and  long- 
continued  cold. 

It  has  been  my  privilege  to  see  and  have  under  treatment  only 
cases  caused  by  calculi.  Primarily  these  cases  probably  start  from 
an  embolus,  as  of  a  clot  of  blood,  or  a  uric-acid  crystal,  which  lodges 
in  one  of  the  minute  capillary  blood-vessels  of  the  gland,  thus  form- 
ing a  nucleus  around  which  the  calcular  deposit  is  built  up.  As  the 
size  of  the  calculus  grows,  an  uncomfortable  feeling  in  the  region  is 
noticed,  which  increases  as  the  augmentation  of  the  deposit  goes  on, 
until  severe  neuralgic  pains  are  experienced.  The  sufferer  is  then 
liable  to  go  through  a  protracted  treatment  for  neuralgia  before  sup- 
puration takes  place.  As  this  occurs  a  severe  chill  (rigor)  is  mani- 
fested, and  very  soon  the  true  nature  of  the  disease  is  determined. 
It  is  no  uncommon  occurrence  for  the  discharge  of  pus  to  take  place 
through  the  duct  from  the  gland  leading  into  the  mouth.  This  may 
go  on  for  months,  and  even  for  years,  before  the  duct  by  some  means 
becomes  clogged,  and  the  discharge  in  that  direction  is  stopped. 
The  pus  accumulating  rapidly,  another  exit  will  soon  be  made,  which 
in  some  instances  is  out  through  the  skin  :  in  the  case  of  the  parotid, 
near  the  angle  of  the  jaw  ;  and  with  the  submaxillary  and  sublingual 
below  the  inferior  maxilla,  in  their  respective  neighborhoods.  More 
frequently,  however,  the  discharge  is  through  the  mucous  membrane 
into  the  mouth. 

The  treatment  of  these  abscesses  consists  in  removing  the  calculus 
and  washing  out  the  abscess  with  antiseptics.  The  removal  of  the 
calculus,  however,  is  no  slight  undertaking.  In  fact,  it  is  one  of  the 
most  delicate  and  difficult  operations  the  surgeon  is  called  upon  to 
perform,  provided  it  is  done  in  the  most  conservative  manner.  It 
consists  in  enlarging  the  opening  through  which  the  pus  is  discharg- 
ing, when  with  a  long,  delicate  instrument  with  a  minute  spoon- 
shaped  end,  made  especially  for  the  case,  the  stone  is  removed. 
This  may  be  done  in  a  few  minutes,  or  it  may  take  hours. 

Should  the  calculus  form  near  the  opening  to  the  duct  leading  to 
the  mouth  from  either  the  submaxillary  or  sublingual  glands,  it  may 
be  forced  forward,  after  suppuration   has  occurred,   into  the  duct. 


136  DENTAL   PATHOLOGY   AND    PRACTICE. 

forming  a  plug.     The  saliva,  being  prevented  from  passing,  accumu-  ■ 
lates,  distends  the  duct,  until  the  annoyance  to   the  patient  causes 
him  to  consult  a  surgeon,  when  a  tumor,  soft,  fluctuating,  and  trans- 
lucent, is  found  under  the  tongue.     Upon  careful  examination,  the 
calculus  may  be  located  with  the  finger. 

The  treatment  of  such  a  tumor  consists  in  opening  the  cyst,  re- 
moving the  stone,  and  thoroughly  cleansing  the  sac  with  antiseptic 
washes.  An  astringent  wash  may  be  used  for  some  days  by  the 
patient,  to  facilitate  the  healing  process.  A  false  opening  for  the  dis- 
charge of  saliva  will  in  most  cases  be  established  at  the  point  where 
the  tumor  was  opened. 


CHAPTER   XVI. 

SALIVARY  CALCULUS   AND   PYORRHEA   ALVEOLARIS. 

These  lesions  are  so  often  referred  to  by  writers  and  speakers 
as  one  and  the  same  condition,  that  I  propose  to  consider  them  to- 
gether ;  not  that  I  believe  them  to  be  essentially  the  same,  for  I  do 
not.  Salivary  calculus  I  hold  to  be  an  evidence  of  organic  dis- 
turbance, or  functional  disorder  of  the  digestive  tract,  or  of  the 
kidneys  or  liver,  as  a  result  of  which  the  excrementitious  materials 
are  not  fully  eliminated  from  the  body.  Prominent  among  these  waste 
products  of  nutrition  is  the  excess  of  lime-salts  taken  into  the  system 
which  should  pass  out  through  these  natural  channels.  These  salts 
are  in  consequence  retained  in  the  circulation  until  they  find  some 
other  mode  of  exit,  mostly  through  the  salivary  glands.  This  is 
generally  termed  a  constitutional  disturbance,  manifesting  itself  locally 
by  the  excessive  calcareous  deposit  upon  the  teeth,  and  often  in  the 
salivary  and  other  glandular  structures.  One  of  the  most  marked 
cases  I  have  ever  seen  was  in  the  mouth  of  a  patient  who  was  suffering 
from  diabetes,  which  caused  his  death  in  a  few  years. 

It  is  very  evident  that  with  every  organ  in  the  body  in  normal 
condition,  i.e.,  in  perfect  health,  consequently  performing  its  function, 
excessive  salivary  calculus  would  be  unknown. 

On  the  other  hand,  pyorrhea  alveolaris  is  found  to  attack  teeth  in 
the  mouths  of  many  persons  who  are  never  troubled  with  excessive 
calcular  deposits  upon  their  teeth.  Both  conditions  may  of  course 
be  present,  a  circumstance  which  very  greatly  complicates  the  case  so 
far  as  treatment  is  concerned. 

Pyorrhea  alveolaris  (discharge  of  pus  from  the  alveolus) — under- 
stood by  laymen  as  a  disease  of  the  gums  which  results  in  the  loss  of 


SALIVARY    CALCULUS   AND    PYORRHEA   ALVEOLARIS.  1 37 

the  teeth — is  a  condition  (I  hardly  think  it  should  be  called  a  disease) 
which  has  been  more  or  less  prevalent  from  time  immemorial.  It 
would  seem  that  with  the  ancients  it  was  the  only  condition  that  de- 
manded the  removal  of  the  teeth,  as  lead  or  copper  forceps  are  the 
instruments  for  that  purpose  spoken  of  in  ancient  history,  indicating 
that  they  had  become  extremely  loose,  and  their  sockets  nearly  or 
quite  destroyed  before  their  extraction  was  resorted  to. 

Let  us  consider  for  a  moment  the  primary  cause  of  pyorrhea.  Is 
it  an  excessive  deposit  of  calcareous  matter  upon  the  teeth  ?  From 
my  studies  and  experience  I  should  say  no,  and  I  believe  this  would 
be  the  answer  of  every  observing  practitioner.  Does  it  not  begin  in 
the  mouths  of  children  who  habitually  neglect  their  teeth  so  far  as 
personal  care  is  concerned,  and  who  never  seek  the  services  of  a 
dentist,  by  an  accumulation  of  particles  of  food  under  the  free  margin 
of  the  gums  ?  This  serves  as  a  lodgment  for  any  lime-salts  which 
come  that  way  in  the  saliva,  so  that  at  the  age  of  ten  or  twelve 
years  or  earlier  a  narrow  ring  of  tartar  may  be  found  under  the  gum. 
Unless  removed,  this  slowly  increases  until  marked  gingivitis  is  ob- 
servable. At  this  time  if  a  small  portion  of  the  soft  mixture  be  taken 
from  under  the  gum,  mounted  upon  a  slide,  and  placed  under  the 
microscope,  pus-corpuscles  will  be  found  in  quite  large  numbers, 
showing  that  ulceration  has  already  commenced. 

If  this  case  be  let  alone  and  watched,  it  will  be  found  that  by  the 
time  the  patient,  or  rather  person,  is  forty  years  old,  or  perhaps 
much  earlier,  the  teeth  will  have  become  loose,  their  sockets  nearly 
or  quite  destroyed,  and  the  gums  will  have  resumed  a  turgid,  hyper- 
emic,  and  ulcerating  condition,  with  pus  constantly  exuding  from  the 
sockets  of  the  soft  tissue,  to  which  the  teeth  are  now  attached. 

The  progress  of  the  destruction  of  tissue  is  now  so  rapid  that  in  a 
few  years  more  these  same  persons  will  be  masticating  upon  their 
gums,  or  wearing  a  beautiful  set  of  artificial  teeth. 

Another  and  very  prevalent  cause  of  pyorrhea  is  mercurial  poison- 
ing. It  is  well  known  that  mercury,  or  its  salts,  has  a  very  irritating 
effect  upon  the  salivary  glands,  causing  them  to  secrete  an  excessive 
amount  of  saliva,  which,  in  turn,  is  poured  into  the  mouth  through 
the  ducts  leading  from  the  glands.  It  is  also  well  known  that  the 
active  principle  of  saliva — ptyalin — in  excess  is  a  powerful  irritant  to 
the  mucous  membrane  of  the  mouth.  This  irritation  very  soon  be- 
comes a  marked  inflammation,  especially  around  the  teeth.  By  this 
inflammation  circulation  is  impeded,  the  nourishment  of  the  gum 
ceases,  and  its  detachment  from  the  necks  of  the  teeth  is  the  result. 
Thus  a  pocket  is  formed  for  the  reception  of  particles  of  food,  lime- 
salts,  etc.  It  must  be  borne  in  mind  that  in  this  position  and  under 
these  circumstances  lime-salts  need  not  come  from  the  saliva  at  all,  as 


138  DENTAL   PATHOLOGY  AND    PRACTICE. 

the  periosteum  (pericementum),  which  has  taken  on  the  inflammatory- 
stage,  its  functional  activity  therefore  being  greatly  stimulated,  is 
working  hard  to  protect  itself  from  further  injury,  by  secreting  in 
excess  this  ingredient  of  the  tartar.  All  the  stages  known,  ' '  from 
start  to  finish,"  in  pyorrhea  alveolaris,  are  observable  in  these  cases 
of  ptyalism. 

It  will  be  observed  that  in  neither  of  the  typical  cases  of  this  tooth- 
or  socket-destroying  malady  is  there  any  general  disturbance,  neces- 
sarily, of  any  organ  or  set  of  organs,  except  in  the  second,  where 
the  salivary  glands  become  involved  temporarily. 

Treatment. — In  considering  the  treatment  of  salivary  calculus,  it 
must  first  be  observed  that  we  have  present  in  the  mouth  evidences 
of  some  organic  or  functional  disorder,  and  that  the  case  is  one  which 
should  be  referred  to  the  general  practitioner.  Locally,  however,  all 
that  is  possible  must  be  done  to  prevent  permanent  injury  to  the 
teeth  and  gums.  This  consists  in  securing  and  maintaining  as  thor- 
ough cleanliness  as  possible.  The  patient  should  be  instructed  to 
brush  the  teeth  inside  and  out,  after  each  meal,  and  have  them 
cleansed  by  the  dentist  at  least  four  times  a  year.  In  order  to  fur- 
ther the  work  of  cleansing,  and  as  a  prophylactic  against  caries,  a 
suitable  dentifrice  should  be  recommended.  This,  together  with  the 
proper  kind  of  brush  to  use,  and  the  manner  of  using  it,  will  consti- 
tute the  directions  for  the  local  care  of  the  teeth,  except  the  removal 
of  portions  of  food  from  between  them,  which  can  be  best  done  by 
the  use  of  quill  toothpicks,  and  silk.  For  general  use  as  a  dentifrice 
I  would  recommend  what  is  known  in  the  market  as  Handicap  tooth- 
powder.  Where  teeth  decay  rapidly,  I  would  recommend  the  follow- 
ing as  a  prophylactic  (antiseptic)  : 

R  — Precip.  chalk,  .^  ij  ; 
Pulv.  orris  root, 
Piilv.  Castile  soap,  aa  ^j  ; 
Bicarbonate  of  soda,  .^  ss  ; 
Salicylic  acid,  gr.  xij. 
Flavor  with  peppermint,  wintergreen,  and  anise  to  suit  the  taste. 

The  tooth-brush  best  calculated  to  keep  the  teeth  clean,  with  the 
least  amount  of  brushing,  should  be  composed  of  four  rows  of  bristles, 
not  stiff"  nor  too  soft,  set  as  close  together  as  practicable,  so  that  a 
very  narrow  brush  is  the  result.  With  such  a  brush  the  teeth  can 
readily  be  brushed  longitudinally  (up  and  down).  Cross-brushing 
should  be  scrupulously  avoided.  It  will  be  observed  that  with  a  brush 
such  as  described  the  slightest  movement  will  produce  friction  upon 
the  teeth,  so  that  the  minimum  amount  of  time  may  be  devoted  to 
this  part  of  the  toilet,  with  clean  teeth  as  the  result. 

In  pyorrhea  alveolaris  we  have  a  different  condition  to  deal  with. 


SALIVARY   CALCULUS   AND    PYORRHEA   ALVEOLARIS.  I39 

There  being  no  evidence  of  any  organic  or  functional  disorder,  the 
case  is  amenable  to  local  treatment  only.  We  are  often  asked  if  such 
cases  can  be  cured.  The  answer  is,  if  taken  at  the  beginning  of  the 
trouble,  yes  ;  while  if  the  accumulation  upon  the  teeth  is  consider- 
able, the  remaining  periosteum  thickened,  the  teeth  consequently  more 
or  less  loose,  the  answer  is,  no,  but  that  the  mouth  can  be  rendered 
healthy,  the  discharge  of  pus  from  the  sockets  stopped,  and  the  teeth 
made  firm  again  in  the  remaining  portions  of  the  sockets.  The  only 
change  from  a  normal  condition  will  be  a  loss  of  more  or  less  of  the 
alveolus  and  an  atrophied  condition  of  the  gums  around  the  teeth, 
leaving  not  only  their  necks,  but,  in  many  cases,  a  large  portion  of 
their  roots  uncovered. 

Many  remedies,  as  astringents,  stimulants,  escharotics,  etc.,  have 
been  recommended,  and  even  constitutional  treatment  has  been 
resorted  to  with,  so  far  as  my  knowledge  and  experience  goes,  very 
questionable  success.  The  real  remedy  is  the  careful  removal  of  all 
foreign  substances  from  the  roots  of  the  teeth.  This  alone  will  suffice, 
and  nature,  "  the  great  restorer,"  will  do  the  healing  of  the  soft  parts. 
Should  the  alveolus  be  exposed  and  a  portion  of  it  dead,  as  is  some- 
times the  case,  of  course  it  must  be  thoroughly  cut  away.  This, 
however,  in  some  few  cases  I  have  seen,  is  not  followed  by  recovery 
as  readily  as  one  could  wish. 

Should  it  be  deemed  advisable  to  apply  astringents,  etc. ,  to  facilitate 
the  healing  of  the  soft  parts  or  allay  pain,  after  cleansing  thoroughly 
the  following  are  recommended  : 

R — Tannic  acid, 
Carbolic  acid, 
Tr.  iodin,  aa  5  ss  ;  j-  Astringent,  antiseptic,  and  stimulant. 


Glycerin, 

Distilled  water,  aa  ^  ss.  J 
M. 
Sig.— Spray. 

If  the  parts  are  painful  after  the  removal  of  tartar,  the  following 
will  be  found  very  grateful  to  the  patient: 


R — Carbolic  acid, 

Tannic  acid,  aa  5  ss  ; 

Sulphate  of  morphia,  gr.  iv  ; 

Glycerin, 

Distilled  water,  aa  ,f  ss. 

M 
Sig.— Spray. 


-  Sedative,  antiseptic,  and  astringent. 


140 


DENTAL    PATHOLOGY   AND    PRACTICE. 
Fig.  57. 


Mouth  and  Throat  Spray. 
To  be  used  in  most  cases  and  varieties  of  stomatitis,  pharyngitis,  or  laryngitis. 

The  above  cut  represents  the  apparatus  with  which  the  foregoing 
remedies  are  appHed  in  spraying  lacerated  gums,  or  any  inflamed  con- 
dition of  the  mucous  membrane  of  the  mouth  or  throat  where  such 
treatment  is  considered  proper. 

The  proper  mode  of  removing  the  tartar  from  the  roots  of  teeth  is 
greatly  a  matter  of  personal  fancy.  With  some  the  instruments 
used  are  of  a  chisel-like  shape,  and  the  movement  is  a  pushing  one 
toward  the  end  of  the  root.  This  proceeding  I  object  to  seriously, 
as  it  is  productive  of  an  unnecessary  amount  of  laceration  of  the  soft 
parts,  and,  consequently,  unnecessarily  painful.  Of  course  cocain 
(four  per  cent,  solution)  may  be  used  to  render  the  parts  in  a  measure 
insensible  to  pain,  but  it  does  not  lessen  the  laceration.  In  fact,  I 
am  inclined  to  think  that  under  its  use  the  parts  are  injured  consider- 
ably more  than  when  the  work  is  done  without  it, 

I  have  always  followed  the  other  mode  of  procedure, — viz,  a  pull- 
ing movement  for  the  removal  of  the  deposits.  It  has  been  my 
pleasure  to  have  introduced  at  various  times  three  different  sets  of 
instruments  for  this  work  (see  illustrations),  and  all  of  them  have 
been  constructed  upon  this  principle.  The  laceration  of  the  gum 
and  consequent  pain  to  the  patient  is  greatly  lessened,  and  I  believe 
the  work  is  more  easily  and  thoroughly  done  than  by  the  other  method. 
However,  we  are  such  creatures  of  habit  that  possibly  all  could  not 
operate  in  the-  same  manner,  even  if  special  advantages  were  shown 
in  favor  of  one  particular  mode.  ^ 


SALIVARY    CALCULUS    AND    PYORRHEA   ALVEOLARIS.  14I 

Fig.  58. 


r- 


ill        I 

3  4  S  6  7 

Set  of  Small  Scalers,  No.  L     (1S68.) 


Nos.  I,  3.   For  cleansing  the  anterior  surfaces  of  lower  front  teeth. 

N0S.2,  4,  6.  For  cleansing  the  lingual  surfaces  of  lower  front  teeth. 

Nos.  3,  4,  5.  For  cleansing  labial,  palatal,  and  lateral  surfaces  of 
the  upper  front  teeth,  and  buccal,  palatal,  and  approximal  surfaces  of 
molars  and  bicuspids. 

No.  7.   For  cleansing  under  the  gum  around  upper  front  teeth. 

Nos.  8,  9.   For  cleansing  under  the  gums  of  lower  back  teeth. 

Fig.  59. 


12  13 

Set  of  Scalers,  No.  II. 


142 


DENTAL    PATHOLOGY   AND    PRACTICE. 


These  scalers  are  so  shaped  as  to  cut  either  forward,  backward,  or 
laterally. 

The  following  description  will  indicate  their  special  adaptation,  but 
they  will  be  found  very  useful  for  a  large  variety  of  cases  : 

Nos.  I,  2.  For  removing  calcular  deposits  from  between  the  lower 
front  teeth  anteriorly. 

Nos.  3,  4,  5.  For  the  same  teeth  posteriorly;  also  around  the  necks 
of  all  teeth,  both  upper  and  lower. 

No.  6.  For  the  extreme  lingual  portion  of  the  lower  incisors  and 
cuspids. 

No.  7.  For  any  tooth,  under  the  gum,  to  which  its  shape  is  adapt- 
able. 

No.  8.   For  any  of  the  upper  front  teeth,  under  the  gum. 

Nos.  9  and  10.  For  lingual  portions  of  lower  front  teeth,  under  the 
gum. 

Nos.  ir,  12,  13,  14  are  rights  and  lefts,  for  cleaning  under  the  gum,  s 

of  lower  back  teeth. 

Fig.  60. 


2        3456        7S910 

Set  of  Root  Scalers. 

These  instruments  are  intended  more  particularly  for  cleansing  the 
lateral,  or  approximal,  surfaces  of  the  roots  of  the  teeth.  They  will, 
\^'f^  however,  be  found  useful  in  cleansing  almost  every  surface  of  roots 
in  whatever  location. 

Nos.  I,  2,  3,  6,  7,  8  are  adapted  to  rather  heavy  work  beween  the 
back  teeth,  while  Nos.  4,  5,  9,  10  are  intended  for  the  front  teeth, 
and  the  finer  work  between  the  back  ones. 


FACIAL    NEURALGIA.  143 

CHAPTER   XVII. 

FACIAL   NEURALGIA. 

In  order  to  give  a  clearer  understanding  of  the  diffusion  of  pain 
through  the  face,  head,  and  body  from  irritation  of  the  dental  nerves , 
I  have  thought  it  best  to  quote,  by  permission,  the  excellent  descrip- 
tion of  the  fifth  pair  and  its  connections,  written  by  Professor  Harrison 
Allen. 

The  Fifth  Pair  of  Nerves. 

"  Theji/th  pair  of  nerves  (trifacial,  trigeminus) — the  largest  of  the 
cranial  nerves — arises  by  two  roots — an  anterior  motor  and  a  posterior 
sensory  root — the  latter  bearing  a  ganglion.  The  analogy  between 
it  and  a  spinal  nerve  is  exact. 

' '  The  nerve  has,  therefore,  two  origins,  one  for  each  of  its  roots. 
The  sensory  root  has  been  traced  to  the  lateral  tract  of  the  medulla 
oblongata  behind  the  olivary  body.  Its  precise  point  of  origin  is  not 
certainly  known.  The  motor  root  has  been  generally  said  to  be 
traceable  to  the  anterior  pyramid  of  the  medulla  oblongata,  although 
this  has  been  disputed  by  Alcock.  Both  roots  have  an  apparent 
origin  from  the  medulla  oblongata  from  the  side  of  the  pons  Varolii, 
and  both  remain  distinct  while  within  the  cranium,  and  are  inclosed 
in  the  same  membranous  sheath.  Toward  the  apex  of  the  petrous 
bone,  both  nerves  pass  through  an  opening  of  the  dura  mater,  to 
which,  however,  the  ganglion  remains  firmly  attached.  The  sensory 
root  is  larger  than  the  motor,  less  compactly  arranged,  and  both 
softer  and  coarser.  Its  ganglion,  known  as  the  ganglion  of  Gasser 
(semi-lunar  ganglion),  lies  within  a  shallow  depression  at  the  apex  of 
the  petrous  bone.  It  is  of  crescentic  figure,  with  its  convexity 
directed  forward. 

"It  is  joined  at  its  inner  side  by  several  sympathetic  filaments 
from  the  carotid  plexus.  Minute  recurrent  branches  are  distributed 
from  it  to  the  tentorium,  and  according  to  Luschka,  to  the  dura 
mater  of  the  middle  cerebral  fossa. 

"The  motor  root  lies  beneath  the  ganglion,  a  little  to  the  inner 
side  of  its  center.  It  is  distinct  from  the  ganglion,  and  is  received 
entirely  within  the  inferior  division  of  the  extra-cranial  portion  of  the 
nerve. 

' '  The  nerve  divides  in  advance  of  the  ganglion  into  three  main 
divisions  :  (I)  the  ophthalmic,  (II)  the  siiperior  maxillary,  and  (III) 
the  inferior  maxillary  nerves. 


144  DENTAL    PATHOLOGY    AND    PRACTICE. 

(I)  The  Ophthalmic  Division. 

"  The  nerve,  after  leaving  the  ganghon  of  Gasser,  enters  the  cav- 
ernous sinus  and  passes  forward  and  upward  along  its  outer  wall,  in 
which  situation  it  has  a  plexiform  structure.  It  is  a  somewhat  flat- 
tened cord  of  about  an  inch  in  length.  Just  before  entering  the 
anterior  lacerated  foramen,  it  gives  off  a  small  recurrent  branch  and 
receives  some  sympathetic  filaments.  It  then  divides  into  three 
branches,  the  lachrymal,  th.e  frontal,  and  nasal. 

' '  The  lachrymal  nerve  enters  the  orbit  through  the  narrowest  and 
highest  part  of  the  anterior  lacerated  foramen  in  a  separate  sheath  of 
dura  mater.  It  is  the  smallest  of  the  main  branches  of  the  ophthal- 
mic nerve.  It  keeps  near  the  outer  wall  and  is  in  close  connection 
with  the  periosteum  of  the  orbit,  and  passes  in  a  straight  line  along 
the  upper  border  of  the  external  rectus  muscle  to  the  position  of  the 
lachrymal  gland.  It  here  receives  a  filament  of  the  orbital  branch  of 
the  superior  m,axillary  division,  and  gives  small  filaments  to  the  lach- 
rymal gland  and  the  conjunctiva.  The  nerve  then  pierces  the  palpe- 
bral ligament  and  supplies  the  outer  part  of  the  upper  eyelid,  anasto- 
mosing with  branches  of  the  facial  nerve.  Cruveilhier  describes  a 
small  ascending  temporal  branch  which  is  lost  in  the  integument  of 
the  anterior  temporal  region. 

"  Theyr(?;z/a/ nerve  is  the  continuation  of  the  trunk  of  the  ophthal- 
mic hoth.  in  size  3.n6.  direction.  It  enters  the  orbit  in  the  center  of 
the  anterior  lacerated  foramen.  It  passes  horizontally  forward 
between  the  periosteum  and  the  levator-palpebrae  muscle,  which  it 
crosses  at  an  acute  angle,  and  divides  into  two  unequal  branches  in 
the  supra- trochlear  and  supra-orbital.  The  supra-trochlear,  some- 
times called  the  internal  frontal,  is  as  a  rule  the  smaller  of  the  two, 
and  escapes  from  the  orbit  near  the  pulley  of  the  superior  oblique 
muscle.  It  pierces  the  orbicularis  palpebrarum,  and  turns  upward 
on  the  forehead  to  the  occipito-frontalis  muscle,  terminating  in  the 
integument.  At  the  region  of  the  pulley  it  gives  off  a  descending- 
branch  which  joins  the  iyifra-trochlear  branch  of  the  nasal,  and  gives 
filaments  to  the  upper  eyelid,  and  according  to  Cruveilhier  to  the 
root  of  the  nose. 

' '  The  supra-orbital  branch  passes  from  the  orbit  at  the  supra- 
orbital notch  of  the  frontal  bone.  It  divides  into  ascending  and 
descending  branches.  The  latter  are  two  or  three  in  number,  and 
pass  vertically  downward  in  the  substance  of  the  upper  eyelid  to  sup- 
ply the  mucous  membrane.  Meibomian  glands,  the '  skin  and  hair- 
bulbs  ;  one  of  them  running  horizontally  outward  under  the  orbicu- 
laris palpebrarum  to  anastomose  with  branches  of  the  facial.  The 
ascending  passes  to  the  forehead  as  in  the  preceding  branch,  and, 
sooner  than   it,  perforates  the  occipito-frontalis   muscle,  and  is  dis- 


FACIAL    NEURALGIA.  I45 

tributed  to  the  scalp,  as  far  back  as  the  lambdoidal  suture.  Accord- 
ing to  Cruveilhier,  a  very  remarkable  branch  of  this  nerve  enters  a 
minute  osseous  canal,  beginning  at  the  supra-orbital  foramen,  to 
emerge  from  the  canal  at  the  frontal  eminence,  where  it  becomes 
subcutaneous. 

' '  The  nasal  branch  arises  from  the  under  side  of  the  ophthalmic 
trunk  and  enters  the  orbit  at  the  largest  part  of  the  anterior  lacerated 
foramen,  in  company  with  the  third  (between  the  superior  and  inferior 
branches)  and  fourth  nerves,  and  to  the  inner  side  of  the  frontal. 
According  to  Sappey,  it  here  appears  to  be  surrounded  by  nerve- 
trunks  which  form  for  it  a  sort  of  sheath.  It  pierces  the  ligament 
from  which  arises  the  external  rectus  muscle,  and  passes  between  the 
two  heads  of  the  latter  structure.  It  then  is  inclined  obliquely 
inward,  crossing  the  optic  nerve  and  lying  between  it  and  the  levator 
palpebrae,  superior  oblique,  and  superior  rectus  muscles  to  reach  the 
internal  aspect  of  the  orbit.  It  here  occupies  the  cellular  interval 
which  separates  the  internal  rectus  muscle  from  the  superior  oblique, 
and  divides  into  its  terminal  branches.  Before  division,  the  nasal 
nerve  gives  off  the  following  branches  : 

' '  (a)  A  branch  to  the  ophthalmic  ganglion  which  rises  from  the 
trunk  before  entrance  into  the  orbit  according  to  Cruveilhier,  or  be- 
tween the  heads  of  the  external  rectus  according  to  Arnold.  It  lies 
to  the  outer  side  of  the  optic  nerve,  and  constitutes  the  long  root  of 
the  ophthalmic  ganglion. 

' '  {b)  The  spheno-ethmoidalhrdinch.  is  described  by  Luschka  as  pass- 
ing through  the  posterior  ethmoidal  foramen,  and  thence  to  supply 
the  mucous  lining  of  the  sphenoidal  sinus  and  the  posterior  eth- 
moidal cells  along  the  anterior  border  of  the  body  of  the  sphenoid 
bone. 

' '  (f)  The  long  ciliary  nerves,  two  or  three  in  number,  placed  to 
the  inner  side  of  the  optic  nerve.  They  are  in  connection  with  fila- 
ments from  the  short  ciliary  nerves  {q.  v.),  thence  to  the  sclerotic 
coat  of  the  eye,  and  are  distributed  to  the  anterior  portion  of  the 
eye,  including  the  ciliary  muscles,  cornea,  and  iris. 

"  {d)  According  to  Sappey,  a  few  distinct  filaments  join  the  sym- 
pathetic net-work  about  the  ophthalmic  artery. 

' '  Of  the  terminal  branches,  the  continuation  of  the  nerve  {internal 
nasal)  passes  through  the  anterior  ethmoidal  foramen,  where  it  is 
held  by  a  doubling  of  dura  mater,  to  enter  the  brain- case.  It  runs  a 
short  distance  to  the  outer  side  of  the  olfactory  groove  of  the  eth- 
moid bone,  to  descend  vertically  behind  the  ala  ethmoidalis  into  the 
nose.  It  here  divides  into  two  branches  :  one  (external)  forms  for 
itself  a  canal  or  groove  on  the  under  surface  of  the  nasal  bone,  and 
either  obliquely  perforates  this  structure  to  become  superficial,  or 


146  DENTAL    PATHOLOGY   AND    PRACTICE. 

continues  downward  to  the  free  border  of  the  bone  to  pass  between 
it  and  the  upper  lateral  cartilage,  and  is  then  lost  in  the  skin  of  the 
tip  and  alae  of  the  nose.  The  other  (internal)  is  smaller  than  the 
preceding.  It  crosses  the  roof  of  the  nose,  and  is  distributed  to  the 
mucous  membrane  of  the  nasal  septum  as  it  lies  within  the  nasal 
vestibule. 

' '  The  remaining  terminal  branch  (the  infra-trochlear)  leaves  the 
main  nerve  as  it  lies  beneath  the  superior  oblique  muscle  parallel  to 
the  internal  border  of  the  internal  rectus  muscles. 

"It  receives  a  small  filament  from  th.e  supra-trochlear  n&rve,  and 
escapes  from  the  orbit  at  the  position  of  the  pulley.  It  divides  into 
two  sets  of  branches  ;  one  set  passing  to  the  superficial  structure  of 
the  upper  eyelid,  and  the  other  set  (a  greater  number)  supplying  the 
skin  at  the  root  and  sides  of  the  nose,  and  the  caruncle,  lachrymal 
sac,  and  duct.     They  anastomose  with  th.e  frontal  3ind  facial  nerves, 

(II)  The  Superior  Maxillary  Division. 

' '  The  superior  maxillary  nerve  effects  exit  from  the  cranium 
through  the  round  foramen.  It  is  at  first  somewhat  loosely  fascicu- 
lated, but  afterward  becomes  firmer  as  it  crosses  the  pterygo-maxil- 
lary  fossa,  where  it  is  surrounded  by  fibro-adipose  tissue.  It  is  here 
nearly  straight  and  inclined  a  little  downward.  The  main  course  of 
the  nerve  is  continued  across  the  space,  and  lies  within  the  infra- 
orbital canal.  The  nerve  is  now  called  the  infra- orbital.  The  trunk 
of  the  superior  maxillary  nerve  may  be  described  as  confined  to  the 
pterygo-maxillary  fossa,  the  infra-orbital  being  its  branch  of  continu- 
ation.    This  will,  therefore,  be  first  given. 

' '  The  infra-orbital  nerve  as  it  lies  in  the  infra-orbital  canal  is 
curved  a  little  inward.  It  terminates  at  the  infra-orbital  foramen,  in 
the  sub-orbital  branches,  which  form  a  rich  mesh  of  branches  lying 
beneath  the  levator  labii  superioris.  These  branches  are  arranged, 
according  to  Sappey,  in  three  distinct  sets  :  the  ascending,  which  are 
slender,  generally  two  in  number,  lie  in  a  groove  or  canal  of  the 
bone,  and  penetrate  the  fibers  of  the  superior  elevator  to  be  distrib- 
uted to  the  skin  and  conjunctiva  of  the  lower  eyelid.  One  of  the 
branches  sends  filaments  to  the  facial  at  the  outer  palpebral  angle. 
Among  these  branches  is  one  which  is  directed  inward  and  anasto- 
moses with  the  external  nasal.  The  descending  are  more  numerous 
than  the  preceding.  They  are  distributed  to  the  skin  of  the  upper 
lip,  to  the  glands  thereof,  and  to  the  mucous  membrane  and  adjacent 
gum.  The  internal  are  distributed  to  the  skin  of  the  wing  of  the 
nose  as  well  as  to  the  outer  skin-lining  of  the  nasal  vestibule. 

"Just  before  the  infra-orbital  nerve  terminates  as  above,  it  gives 
off"  the  anterior  dental  branch.     This  nerve  preserves  an   unusual 


FACIAL   NEURALGIA.  I47 

course,  as  follows  :  According  to  Cruveilhier,  it  is  often  so  large  as 
to  be  held  as  one  of  the  two  terminal  branches  of  the  infra-orbital. 
This  description  is  here  adopted.  The  nerve  passes  from  the  main 
trunk  horizontally  inward  within  a  special  canal,  then  vertically- 
downward,  turning  round  the  margin  of  the  anterior  opening  of  the 
corresponding  nasal  fossa  to  reach  the  floor  of  the  fossa.  About  two 
lines  from  the  anterior  orifice  it  expands  into  a  great  number  of  as- 
cending and  descending  filaments.  The  ascending  are  reflected 
upward  within  the  anterior  nasal  spine,  where  they  terminate  ;  the 
descending  supply  dental  nerves  to  the  incisors,  cuspids,  and  first 
bicuspids.  Some  of  the  latter  incline  outward,  and  anastomose  with 
branches  of  the  posterior  deyital  nerve.  In  the  first  and  third  portions 
of  the  above  course  the  nerve  is  deeply  situated  ;  in  the  second  it 
becomes  very  superficial  and  approaches  the  external  table  of  the 
superior  maxilla. 

' '  The  collateral  branches  of  the  superior  maxillary  nerves  are  as 
follows  : 

' '  {a)  The  orbital.  This  branch  arises  directly  in  front  of  the  fora- 
men rotundum  from  the  upper  side  of  the  trunk,  passes  through  the 
spheno-maxillary  fissure  to  the  floor  of  the  orbit,  where  it  divides 
into  two  branches,  the  lachrymal  and  temporo-malar.  The  lachrym,al 
receives  a  branch  from  the  lachrymal  branch  of  the  ophthalmic,  and 
supplies  the  lachrymal  gland.  The  temporo-malar  pierces  the  orbital 
portion  of  the  malar  bone,  and  is  distributed  to  the  anterior  part  of 
the  temporal  muscle  to  join  the  anterior  deep  temporal  branch  of  the 
inferior  m.axillary  nerve.  It  perforates  the  temporal  aponeurosis, 
according  to  Quain,  about  one  inch  above  the  zygoma,  and  ends  in 
cutaneous  filaments  over  the  temple.  The  7nalar  division  lies  first  in 
the  loose  fat  at  the  lower  angle  of  the  orbit,  pierces  the  maxillary 
portions  of  the  malar  bone,  and  divides  into  two  filaments  to  anasto- 
mose with  the  facial  nerve. 

' '  [b)  The  posterior  dental  nerves  arise  from  the  superior  maxillary 
within  the  pterygo-maxillary  fossa.  These  are  arranged  in  two  sets, 
the  superior  and  the  inferior.  The  superior  pass  through  the  base  of 
the  malar  process,  and  are  distributed  to  the  canine  fossa  and  there 
anastomose  with  the  anterior  dental.  The  inferior,  larger  than  the 
preceding,  curve  below  the  malar  process,  and,  passing  through  the 
posterior  dental  foramina,  supply  the  molar  teeth,  outer  wall  of  the 
maxillary  sinus,  and  filaments  to  the  alveoli  and  the  gum  tissues. 
Some  minute  branches  terminate  within  the  superior  maxilla. 

(Ill)  The  Inferior  Maxillary  Division. 

"  The  inferior  maxillary  nerve  escapes  from  the  cranium  through 
the  oval  foramen  of  the  sphenoid  bone.     It  descends  vertically,  and, 


14b  DENTAL    PATHOLOGY   AND    PRACTICE. 

according  to  Luschka,  immediately  gives  off  a  recurrent  branch. 
This  at  once  passes  through  the  spinous  foramen  in  company  with 
the  middle  meningeal  artery,  and  runs  backward  to  the  middle  cere- 
bral fossa,  and  divides  into  an  anterior  and  a  posterior  branch.  Thfe 
former  enters  various  openings  in  the  substance  of  the  greater  wing 
of  the  sphenoid  bone  ;  the  latter  passes  within  the  petro -squamous 
suture  to  the  lining  membrane  of  the  mastoid  cells. 

"  The  main  trunk  of  the  inferior  maxillary  nerve  divides  into  two 
great  branches  :  ( i)  an  anterior  and  smaller  branch,  which  is  for  the 
most  part  motor,  and  (2)  a  posterior  or  larger  branch,  which  is  in  the 
main  sensory. 

"(i)  The  anterior  root  divides  into  the  following  branches  :  (a) 
the  deep  temporal^  (b)  the  masseteric^  {c)  the  internal  pterygoid,  (d) 
the  external  pterygoid,  {e)  the  inylo-hyoid  nerves. 

"(a)  The  deep  temporal  nerves  arise  a  little  distance  below  the 
oval  foramen,  commonly  by  two  roots.  The  anterior  root  unites 
with  the  sensory  filaments  of  the  buccinator  where  the  latter  nerve 
runs  through  or  beneath  the  external  pterygoid  muscle.  The  pos- 
terior root  is  entirely  motor.  The  nerve  passes  at  first  forward,  then 
obliquely  upward  and  outward,  and  finally  vertically  upward  through 
the  deep  part  of  the  temporal  muscle.  It  perforates  the  temporal 
fascia  about  a  finger-breadth  above  the  zygomatic  arch,  and  then 
ascends  beneath  the  skin  to  anastomose  with  the  auriculo -temporal 
znd  facial  nerves. 

' '  {b)  The  masseteric  nerve,  larger  than  the  preceding,  arises 
acutely  from  the  main  nerve  by  a  thick  root  behind  the  deep  temporal, 
with  which  it  may  have  a  common  stem.  It  passes  backward  and 
outward  in  contact  with  the  roof  of  the  zygomatic  fossa,  between  it 
and  the  external  pterygoid  muscle.  It  is  then  reflected  downward 
over  the  upper  part  of  the  muscle  to  gain  the  sigmoid  notch,  upon 
which  it  is  again  deflected  to  descend  vertically  between  the  ramus 
and  the  deep  surface  of  the  masseteric  muscle.  Cruveilhier  asserts 
that  filaments  of  this  nerve  can  be  traced  in  the  substance  of  the  deep 
layer  of  the  muscle  to  its  insertion.  The  branches  of  the  nerve  are, 
— a  small  branch  of  union  with  the  deep  temporal,  a  separate  branch 
to  the  temporal  muscle,  mentioned  by  Sappey  as  the  deep  posterior 
tcmpo?'al,  and  a  branch  to  the  temporo-maxillary  articulation. 

' '  {c)  The  internal  pterygoid  nerve.  This,  the  shortest  branch  of 
the  inferior  maxillary ,  is  interesting  from  its  connection  with  the 
palate  and  ear.  It  arises  from  the  anterior  and  internal  side  of  the 
trunk,  on  the  level  with  the  otic  ganglion.  It  runs  constantly  between 
the  lingual  nerve  and  the  otic  ganglion,  after  passing  through  the 
latter  structure  from  before  backward  to  gain  the  inner  side  of  the 
internal  pterygoid  muscle.     It  sends  a  motor  root  to  the  otic  gan- 


FACIAL    NEURALGIA.  I49 

glion,  a  twig  to  the  tensor  palati  muscle,  and  delicate  filaments  which 
traverse  the  ganglion  to  go  to  the  tensor  tympani  muscle. 

"  (a? )  The  external  pterygoid  nerve.  As  a  rule,  this  branch  is  con- 
fined in  its  distribution  to  the  muscles  of  the  same  name,  and  is  often 
a  twig  from  the  preceding  branch.  Sometimes  it  arises  in  common 
with  the  buccinator. 

"  {e)  The  mylo-hyoid  nerve.  This  nerve,  generally  recognized  aS 
a  branch  of  the  inferior  dental,  has  been  determined  by  Luschka  and 
Sapolini  to  be  a  motor  nerve,  and  as  such  traceable  to  the  motor 
trunk  of  the  inferior  maxillary  nerve.  As  its  name  implies,  it  is 
distributed  to  the  mylo-hyoid  muscle.  It  lies  within  a  faint  groove 
on  the  inner  side  of  the  lower  jaw,  where  it  is  confined  by  fibrous 
membrane.  Some  of  its  filaments  pierce  the  mylo-hyoid  muscle  to 
join  the  Ihigual. 

"  (y)  According  to  Sapolini,  a  motor  branch  of  the  inferior  max- 
illary nerve  passes  along  the  entire  length  of  the  inferior  dental 
canal,  to  be  lost  in  the  soft  parts  about  the  mental  foramen. 

"(2)  The  sensory  division  of  the  inferior  Tnaxillary  nerve  is 
divided  into  the  following  branches  :  (a)  The  auriczdo-temporal,  (U) 
the  buccinator,  {c)  the  lingual,  and  (a?)  the  inferior  dental  nerves. 

' '  (a)  The  auriculo-teinporal  nerve.  This  arises  by  two  unequal 
roots,  between  which  is  seen  the  internal  maxillary  artery.  The 
roots  soon  unite  to  form  a  flattened  trunk,  inclined  with  a  convex 
border  outward  toward  the  condyle  of  the  lower  jaw.  It  then  winds 
round  the  neck  of  the  condyle,  and,  in  the  language  of  Cruveilhier, 
ascends  vertically  between  the  articulation  and  the  external  auditory 
meatus.  It  becomes  subcutaneous  and  divides  into  several  filaments, 
which  may  be  traced  to  the  highest  point  of  the  temporal  fossa. 
During  its  course  the  nerve  gives  off  a  very  remarkable  anastomotic 
branch,  which  arises  behind  the  neck  of  the  condyle,  and  is  reflected 
upon  it  so  as  to  run  forward  beneath  the  facial  nerve,  with  which  it 
is  blended  opposite  the  posterior  border  of  the  masseter  muscle.  It 
may  be  regarded  as  tributary  to  the  facial,  which  becomes  notably 
larger  after  receiving  it.  The  main  nerve  gives  off  some  plexiform 
branches,  directed  horizontally  backward  to  the  temporo-maxillary 
articulation,  as  well  as  to  the  auditory  meatus,  which  enter  between 
the  osseous  and  cartilaginous  portions,  and  sends  a  branch  to  the 
tympanic  membrane.  Of  the  branches,  the  auriciilar,  according  to 
Luschka,  pass  through  the  space  between  the  tragus  and  helix,  to 
the  concave  surface  of  the  auricle.  A  filament  is  directed  toward  the 
handle  of  the  malleus.  Ouain  asserts  that  a  small  branch  joins  the 
otic  ganglion. 

' '  The  main  nerve  accompanies  the  temporal  artery,  about  which  it 


150  DENTAL    PATHOLOGY  AND    PRACTICE. 

forms  a  sort  of  plexus,  and  then  divides  into  filaments  for  the  skin, 
traces  of  which  can  be  detected  as  far  as  the  crown  of  the  head. 
Meckel  mentions  a  branch  of  communication  between  this  and  the 
occipital.  The  lower  division  of  the  nerve  is  as  large  as  the  ascend- 
ing portion.  It  forms  a  plexiform  arrangement  of  fibers  about  the 
internal  maxillary  artery,  behind  the  condyle,  and,  according  to 
Cruveilhier,  sometimes  presents  a  small  ganglion.  Its  branches  go 
to  the  parotid  gland  ;  others  anastomose  with  the  auricularis  magnus 
nerve,  while  another  extremely  fine  filament  joins  the  inferior  dental 
nerve. 

"  (b)  The  buccinator  nerve  arises  from  the  outer  side  of  the  inferior 
maxillary  nerve  by  from  one  to  three  roots,  which  either  perforate 
the  external  pterygoid  muscle  or  pass  between  it  and  the  internal. 
It  rarely  perforates  the  temporal  muscle,  according  to  Cruveilhier. 
The  branches  of  the  nerve  are  then  directed  downward,  between  the 
coronoid  process  of  the  mandible  and  the  tuberosity  of  the  superior 
maxilla,  and  become  superficial  midway  between  the  lobe  of  the  ear 
and  the  angle  of  the  mouth.  Before  reaching  the  cheek,  the  follow- 
ing branches  are  given  off : 

"(i)  Two  or  three  muscular  branches  to  the  external  pterygoid 
muscle. 

"  (2)  Temporal  branch  {anterior  deep^,  which  penetrates  the  thick- 
est portion  of  the  temporal  muscle,  and  ordinarily  unites  with  the 
temporal  branches  of  the  orbifo-temporal  nerve.  It  then  pierces  the 
temporal  aponeurosis,  a  little  beneath  and  behind  the  external  frontal 
process.  It  here  divides  into  a  pencil  of  filaments,  which  for  the 
most  part  terminate  in  the  skin  of  the  temple.  Two  or  three 
branches  anastomose  with  filaments  of  the  facial.  Sometimes  a 
small  branch  becomes  subcutaneous  a  short  distance  above  the  zygo- 
matic arch. 

"  (3)  A  descending  branch,  according  to  Cruveilhier,  supplies  the 
temporal  muscle,  about  its  insertion  in  the  coronoid  process. 

"  Upon  the  cheek  the  biiccinator  nerve  is  divided  into  an  upper  and 
a  lower  branch.  The  upper  is  cutaneous,  and  goes  to  the  skin  of  the 
malar  and  buccal  region.  One  of  them  forms  an  anastomotic  arch 
with  t\ve  facial  behind  the  parotid  duct.  The  lower  branches  are  in 
part  cutaneous  about  the  oral  angle  ;  others  pierce  the  buccinator 
muscle,  to  be  distributed  to  the  buccal  mucous  membrane.  Turner 
has  recorded  an  example  in  which  a  separate  branch  of  the  inferior 
maxillary  nerve  passed  to  the  buccinator  muscle,  while  the  branches 
to  the  mucous  membrane  were  derived  from  the  superior  maxillary 
nerve. 

' '  (<:)  The  lingual  or  gustatory.  This  nerve  lies  between  the  ex- 
ternal pterygoid  muscle  and  the  pharynx,  to  the  inner  side  and  in 


FACIAL   NEURALGIA.  I5I 

front  of  the  inferior  dental  nerve,  to  which  it  is  united  by  a  slender 
commissure  at  its  origin.  It  Hes  directly  beneath  the  mucous  mem- 
brane opposite  the  molar  teeth  ;  passes  thence  beneath  the  mucous 
membrane  of  the  alveolo-lingual  groove,  at  the  floor  of  the  mouth, 
above  the  submaxillary  gland  and  the  mylo-hyoid  muscle,  and  outside 
of  the  hyoglossus,  beneath  the  sublingual  glands  and  over  the  duct  of 
Wharton,  which  latter  structure  it  crosses  at  an  acute  angle. 

"  The  lingual  nerve  is  joined  by  the  chorda  tympani  nerve  during 
the  passage  of  the  former  between  the  pterygoid  muscles.  Although 
this  is  at  first  a  mechanical  union,  the  chorda  tympani  becomes  inti- 
mately associated  with  the  lingual. 

' '  The  branches  of  the  lingual  are  as  follows  :    ■ 

"  (i)  A  communicating  branch  with  the  hypoglossal.  This  remark- 
able nerve  is  described  by  Luschka  as  running  recurrent  in  the  sheath 
of  the  hypoglossus  nerve.  Its  branches  in  part  are  distributed  to  the 
wall  of  the  internal  jugular  vein,  and  in  part  to  the  sinuses  and  can- 
celli  of  the  occipital  bones,  which  are  reached  by  the  branches 
thereto  passing  through  the  anterior  condyloid  foramen. 

' '  (2)  A  small  branch  to  the  palato-glossal  fold,  which  passes  also 
to  the  tonsil. 

"  (3)  Sublingual  branches  to  the  mucous  membrane  of  the  floor  of 
the  mouth  and  gum-tissue. 

"  (4)  Lingual  branches  which  pass  between  the  longitudinal  fibers 
and  those  of  the  genio-hyoglossus  muscle.  Those  to  the  border  of 
the  tongue  are  joined  at  the  level  of  the  middle  third  of  the  hyo- 
glossus muscle  by  a  filament  derived  from  the  mylo-hyoid  muscle. 

"  (5)  Below  it  from  its  convex  surface  branches  are  directed  to  the 
submaxillary  gland. 

"  According  to  Sappey,  the  lingual^  in  addition,  gives  a  few  plexi- 
form  branches  beneath  the  tongue,  and  some  terminal  branches  to 
the  mucous  membrane  about  the  under  surface  of  the  tip  of  the 
tongue  and  the  glands  of  Niihn. 

"  {d)  The  inferior  dental  nerve.  This  nerve  is  directed  downward 
between  the  two  pterygoid  muscles,  and  afterward  between  the  lower 
jaw  and  the  internal  pterygoid  muscle,  from  which  it  is  separated  by 
a  fibrous  lamina.  It  is  here  in  association  with  the  mylo-hyoid  nerve, 
which  is  generally  described  as  a  branch  of  this  nerve.  The  inferior 
dental  in  reality  gives  off  no  branches  outside  the  lower  jaw,  save  one 
which  unites  with  the  lingual. 

"The  nerve  enters  the  dental  canal  by  the  posterior  dental  fora- 
men, and  passes  along  the  entire  length  of  the  dental  canal,  giving 
filaments  of  supply  to  the  molar  and  bicuspid  teeth.  At  the  anterior 
(mental)  dental  foramen  the  nerve  divides  into  two  sets  of  branches; 
by  far  the  larger  set  effects  exit  through  the  mental  foramen,  where 


152  DENTAL    PATHOLOGY    AND    PRACTICE. 

Its  branches  are  arranged  in  a  plexiform  fashion  into  two  planes  :  one 
anterior,  to  supply  the  skin,  lip,  and  inferior  part  of  the  cheek  ;  the 
other  posterior,  which  crosses  between  the  muscular  layer  and  the 
glandular  layer  to  terminate  in  part  in  the  glands  and  in  part  in  the 
labial  mucous  membrane.  The  other  set,  confined  to  a  few  delicate 
filaments,  continues  with  the  cancelli  of  the  lower  jaw,  as  far  as  the 
symphysis,  to  supply  the  cuspid  and  incisor  teeth. 

The  Ganglia  of  the  Fifth  Pair  of  Nerves. 

"  The  fifth  pair  of  nerves  is  remarkable  for  the  possession  of  a 
number  of  accessory  ganglia.  These  are  in  close  association  with 
the  sympathetic  system.  Each  ganglion  possesses,  in  addition  to  its 
nerves  of  distribution,  a  motor-sensory  and  a  sympathetic  filament. 

"  These  ganglia  are  usually  enumerated  as  follows  : 

"(I)  The  ophthalmic,  or  lenticular,  pertaining  to  the  ophthalmic 
division. 

"(II)  The  spheno-palatine,  pertaining  to  the  superior  maxillary 
division. 

"(Ill)  The  otic;  and 

"(IV)  The  submaxillary  ganglia,  pertaining  to  the  inferior  max- 
illary division. 

* '  In  addition  to  these,  an  inconstant  accession  of  ganglionic  mat- 
ter may  be  met  with  on  the  face  beneath  the  infra-orbital  foramen, 
and  within  the  anterior  palatal  foramen.  These  are  not  described 
here. 

(I)  The  Ophthalmic  Ganglion, 

"  The  ophthalmic  ganglion  is  small,  flattish,  lenticular,  or  more  or 
less  quadrangular  in  shape.  It  has  a  diameter  of  about  one  line.  It 
is  placed  between  the  external  rectus  muscle  and  the  optic  nerve,  at 
about  its  posterior  third,  and  is  generally  in  contact  with  the  ophthal- 
mic artery.  It  lies  two  or  three  lines  from  the  optic  foramen,  sur- 
rounded by  a  quantity  of  loose  fat. 

' '  The  branches  of  communication  of  this  ganglion  are  as  follows  : 

"  (a)  Motor  branch,  from  the  inferior  division  of  the  third  cranial 
nerve, — short  and  thick.  This  branch  is  sometimes  duplicated.  It 
joins  the  ganglion  at  its  posterior  inferior  angle. 

"((^)  Sensory  branch,  from  the  ?iosal  nerve,  while  still  retained  in 
the  cavernous  sinus.  It  is  long  and  slender,  and  joins  the  ganglion 
at  its  posterior  superior  angle.  Hyrtl  mentions  an  occasional  junc- 
tion from  a  filament  of  the  lachrymal  nerve. 

"(f)  Sympathetic  branch,  from  the  parotid  plexus, — and  thence, 
according  to  Cruveilhier,  from  the  superior  cervical  ganglion.  It 
may  join  the  sensory  filament  instead  of  the  ganglion. 


FACIAL    NEURALGIA.  153 

' '  The  branches  of  distribution  of  the  ophthalmic  ganghon  are  the 
short  ciliary  nerves.  They  arise  by  two  distinct  bundles,  each  com- 
posed of  six  to  eight  filaments.  Those  from  the  anterior  superior 
angle  pass  between  the  optic  nerve  and  the  superior  straight  muscle. 
Those  from  the  anterior  inferior  pass  between  the  optic  nerve  and  the 
inferior  straight  muscle.  They  are  joined  by  some  filaments  of  the 
nasal  nerve,  and  are  distributed  to  the  eyeball  by  piercing  the  scle- 
rotic coat  and  passing  forward  between  it  and  the  choroid  coat,  as 
far  as  the  iris,  within  which  they  are  lost. 

(II)  The  Spheno-Palatine  Ganglion. 

' '  The  spheno-palatine  ganglion  is  the  largest  of  the  ganglia  of  the 
fifth  pair.  It  is  situated  in  the  pterygo-maxillary  fossa  close  to  the 
spheno-palatine  foramen.  It  is  of  a  triangular  or  parallelogram 
shape.  Its  posterior  extremity  is  tapering,  and  composed  of  gray 
matter.  Its  anterior  is  broader,  and  contains  little  or  no  gray  matter. 
The  ganglion  is  surrounded  by  fat.     Its  branches  are  as  follows  : 

' '  («)  The  orbital  branches.  These  are  delicate,  and  enter  the 
orbit  through  the  spheno-maxillary  fissure,  and  are  lost  about  the 
periosteum.  Some,  according  to  Arnold  and  Longet,  are  distributed 
to  the  neurilemma  of  the  optic  nerve,  Luschka  describes  among  this 
group,  under  the  name  of  the  spheno-ethmoid  branches,  two  or  three 
filaments  which  pass  through  the  spheno-maxillary  fissure,  to  ascend 
to  the  hinder  part  of  the  internal  orbital  wall,  where  they  pass 
through  the  posterior  ethmoidal  foramen,  and  enter  the  brain-case. 
They  reach  the  sphenoidal  sinus,  and  supply  the  posterior  ethmoidal 
cells,  by  passing  between  the  sphenoid  and  ethmoid  bones,  Boch 
describes  a  branch  of  the  orbital,  ascending  to  join  the  sixth  nerve, 

"(3)  The  nasal  branches.  These  pass  horizontally  inward,  and 
enter  the  nasal  cavity  through  the  spheno-palatine  foramen. 

"They  consist  of  two  branches,  an  upper  nasal  v4\\\q\x  consists  of 
several  small  nerves  which  supply  the  upper  and  posterior  part  of  the 
septum,  the  mucous  membrane  covering  the  superior  and  middle 
nasal  scrolls,  and  the  posterior  ethmoidal  cells.  The  larger  and 
more  important  division  of  the  waj-^/ branches  (naso-palatine)  crosses 
the  roof  of  the  nasal  chamber,  and  is  directed  vertically  downward, 
then  horizontally  forward  along  the  nasal  septum,  to  which,  however, 
it  gives  no  branch,  nearly  joins  its  fellow  of  the  opposite  side,  and 
emerges  from  the  nasal  chamber  to  be  distributed  to  the  anterior 
portion  of  the  hard  palate  through  the  incisorial  or  anterior  palatine 
foramen.  Within  this  foramen,  the  nerve  of  the  right  side  is  in 
advance  of  the  left. 

"(c)  The  descending  palatal  branches.     These  consist  of  three 


154  DENTAL    PATHOLOGY    AND    PRACTICE. 

sets  :  the  large  anterior  palatal,  the  small  posterior  palatal,  and  the 
small  external. 

' '  The  large  anterior  palatal  descends  within  the  posterior  palatal 
canal,  to  emerge  thence  to  be  distributed  to  the  side  of  the  hard  pal- 
ate in  company  with  the  posterior  palatine  artery  ;  it  lies  in  a  groove 
of  the  hard  palate,  and  extends  nearly  to  the  incisor  teeth.  It  sup- 
plies the  gums,  glands,  and  mucous  membrane,  and  anastomoses 
in  front  with  the  naso-palatine  nerves.  While  within  the  canal  it 
sends  a  small  branch  to  the  middle  and  lower  turbinate,  and  just 
before  leaving  it  another  small  branch  to  the  latter  ;  about  the  same 
point  with  the  foregoing,  a  filament  from  the  hinder  part  of  the  trunk 
passes  through  a  separate  canal  to  the  soft  palate.  The  latter 
branches  are  described  by  most  authors  when  well  developed  under 
the  name  of  the  middle  palatine  nerves. 

' '  The  small  posterior  palatal  enters  the  small  posterior  palatine 
canal,  and  is  divided  as  follows  :  one  set  of  filaments  proceeds  to  the 
levator  palati  and  azygos-uvulae  muscles,  and  another  sensory  set  to 
the  mucous  membrane  on  the  superior  aspect  of  the  soft  palate  and 
its  glands.  According  to  Sappey,  this  nerve  must  be  held  as  a  de- 
scending branch  of  the  great  superficial  petrosal,  which  in  turn  is  a 
member  of  the  facial  group  of  filaments. 

' '  The  external  branches  are  very  small.  They  pass  between  the 
superior  maxilla  and  the  external  pterygoid  muscle,  enter  a  small 
canal  between  the  superior  maxilla  and  the  pterygoid  process  of  the 
palatal  bone,  and  are  thence  distributed  to  the  uvula,  tonsil,  and 
soft  palate. 

' '  id)  The  Vidian  or  pterygoid  branch.  This  nerve  is  continuous 
with  the  gray  matter  of  the  ganglion.  It  contains  gray  matter  for 
some  distance  from  its  origin  ;  is  finally  continuous  as  a  distinct 
trunk  with  the  inferior  or  deep  petrosal,  and  is  lost  in  the  sympa- 
thetic net-work  about  the  carotid  artery.  Sometimes  it  arises  as  a 
distinct  branch  from  the  spheno-palatine  ganglion.  The  Vidian  is 
directed  directly  backward,  and,  passing  through  the  Vidian  canal  of 
the  sphenoid  bone,  pierces  the  fibro-cartilage  occupying  the  median 
lacerated  foramen,  within  which  the  carotid  branch  is  given  off,  and 
becomes  the  great  superficial  petrosal  nerve.  This  is  now  directed 
outward,  passes  beneath  the  ganglion  of  Gasser,  from  which  it  is 
separated  by  a  delicate  leaf  of  the  dura  mater.  It  thence  passes  to 
the  anterior  face  of  the  petrous  bone,  and  enters  the  hiatus  Fallopii 
to  reach  the  yaa'a/ nerve  at  the  intumescentia  gangliformis.  This, 
the  standard  description,  it  is  now  believed,  should  be  so  modified  as 
to  read  :  that  the  nerve  arises  from  the  facial  nerve,  passes  toward, 
not  into  the  ganglion,  and  is  continued  thence  to  the  palate  as  the 
posterior  palatal  nerve. 


FACIAL    NEURALGIA.  155 

"(e)  The  p/iaryngea/ branches.  These  are  often  described  as 
branches  of  the  Vidian.  They  may,  however,  rise  distinct ;  they 
are  placed  within  the  pterygo-palatine  canal,  whence  they  appear  on 
the  lateral  wall  of  the  pharynx,  about  and  behind  the  orifice  of  the 
Eustachian  tube. 

' '  (/")  The  superior  branches.  These  are  generally  two  in  number, 
and  serve  to  unite  the  trunk  of  the  superior  maxillary  nerve  to  the 
trunk  of  the  ganglion.  Many  of  the  fibers  pass  directly  through  the 
gray  matter  of  this  structure  to  appear  below  as  the  descending  ^<a;/- 
atine  branches.  Luschka  would  therefore  remove  the  consideration 
of  the  latter  nerves  from  the  ganglion,  and  revert  to  them  as 
branches  of  the  main  nerve-trunk. 

(Ill)  The  Otic  Ganglion. 

"  The  otic  ganglion  is  placed  to  the  inner  side  of  the  infe?'ior  max- 
illary nerve,  a  little  above  the  origin  of  the  auriculo-temporal 
branch.  Its  external  face  answers  to  the  point  of  union  of  the 
motor  trunk  with  the  sensory.  Its  inner  surface  lies  beneath  the  car- 
tilaginous portion  of  the  Eustachian  tube,  and  on  the  tensor  palati 
muscle.  Behind  it  is  the  middle  meningeal  artery.  It  is  of  a  yellow- 
ish-gray color,  and  presents  an  ovoid  shape,  flat,  and  of  soft  con- 
sistence. 

' '  Its  branches  of  connection  are  as  follows  : 

"(a)  Motor  root  (short),  from  the  internal  pterygoid  nerve, 
where  it  pierces  the  ganglion. 

"  (J))  Sensory  root  (long),  from  the  superficial  peh^osal  nerve, 
which  in  turn  is  derived  from  the  tympanic  branch  of  the  glosso- 
pharyngeal within  the  temporal  bone.  A  branch  of  this  nerve  joins 
the  facial  at  the  gangliform  swelling. 

"  {c)  Sympathetic,  derived  from  the  plexus  about  the  middle  menin- 
geal artery. 

"  (d)  A  branch  of  union  with  the  aicricular  hranch  of  the  auriculo- 
temporal nerve. 

' '  The  otic  ganglion  sends  branches  to  the  tensor  tympani  muscle 
and  the  tensor  palati  muscle  ;  and  sensory  branches,  two  or  three  in 
number,  reach  the  mucous  lining  of  the  middle  ear. 

(IV)  The  Submaxillary  Ganglion. 

' '  The  submaxillary  ganglion  is  the  most  variable  of  the  ganglia  of 
the  fifth  pair.  Commonly  of  a  triangular  shape,  and  rather  thick,  it 
may  be  plexiform  or  absent.  It  is  situated  between  the  outer  side  of 
the  hyoglossus  muscle  and  the  deep  part  of  the  submaxillary  gland. 

"  It  presents  (a)  a  short  sensory  root  from  the  lingual  ;  (^b)  a  long 


156  DENTAL    PATHOLOGY   AND    PRACTICE. 

motor  root  from  the  fibers  continuous  with  the  chorda  tympa^ii 
nerve  ;  and  {c)  sympathetic  filaments  ft-om  the  plexus  about  the  facial 
artery. 

"  It  sends  off  numerous  branches  of  distribution  to  the  submaxil- 
lary gland,  walls  of  the  duct  of  Wharton,  as  well  as  some  ascending- 
branches  to  the  wall  filaments  of  the  lingual,  a  plexiform  arrange- 
ment at  the  side  of  the  tongue.  No  branches  are  given  to  muscle — in 
marked  contrast  to  the  branches  of  distribution  of  the  otic  ganglion. 

Function  of  the  Fifth  Nerve.* 

"  '  The  determination  of  the  functions  of  the  roots  of  spinal  nerves 
has  afforded  the  clue  to  that  of  the  functions  of  the  roots  of  the  fifth 
nerve.  The  analogy  of  the  smaller  root  of  the  fifth  with  the  anterior 
spinal  root,  and  of  the  larger  one  with  the  posterior  spinal  root,  has 
long  been  admitted  by  anatomists.  Hence  an  analogy  of  function 
must  be  admitted,  and  the  former  must  be  viewed  as  consisting  of 
motor  fibers,  the  latter  of  sensitive  ones  ;  and  by  tracing  each  of  the 
three  great  divisions  of  the  nerve,  we  may  determine  its  function  by 
its  constitution,  according  as  it  derives  its  fibers  from  either  root  or 
from  both.  The  ophthalmic  and  superior  maxillary  are  composed  of 
fibers  derived  exclusively  from  the  larger  root  ;  they  are,  therefore, 
sensitive  nerves.  The  inferior  maxillary  consists  of  fibers  derived 
from  both  roots,  and  consequently  is  both  motor  and  sensitive.  Sir 
C.  Bell,  in  his  original  exposition  of  the  functions  of  this  nerve,  fell 
into  error  from  having  neglected  to  avail  himself  of  this  method  of 
analyzing  the  constitution  of  each  of  its  three  divisions,  from  which 
he  would  have  seen  that  it  is  the  inferior  maxillary  alone  which  derives 
its  fibers  from  both  roots,  and  which  perfectly  resembles  a  spinal 
nerve  in  constitution. 

"  'The  distribution  of  the  three  divisions  of  the  fifth  nerve  con- 
firms most  amply  the  view  of  its  physiology  suggested  by  the  anat- 
omy of  its  origin.  The  ophthalmic  and  superior  maxillary  are 
distributed  entirely  to  sentient  surfaces,  or  anastomose  with  motor 
nerves  (the  facial).  They  supply  the  skin  of  the  forehead,  of  the 
eyelids,  the  conjunctiva,  the  eyeball,  the  mucous  membrane  of  the 
nostrils,  the  integuments  of  the  face,  the  upper  lip,  the  nose,  the 
beard  on  the  upper  lip,  the  integument  of  the  ear,  the  temple,  and 
the  whiskers  ;  they  are  the  sensitive  nerves  to  these  regions.  The 
inferior  maxillary  has  two  distinct  sets  of  branches  ;  the  one  by 
which  the  muscles  of  mastication  are  supplied,  the  other,  which  goes 
to  the  integuments  of  the  lower  lip  and  chin,  and  the  beard,  and  the 
mucous  membrane  of  the  mouth  and  tongue.     This  nerve  is,  there- 

*  See  Todd  and  Bowman. 


FACIAL   NEURALGIA.  157 

fore,  the  nerve  of  mastication,  and  of  sensation  to  the  surfaces  above 
named. 

"'Repeated  experiments  in  the  hands  of  various  physiologists, 
none  of  which,  however,  were  more  conclusive  than  those  of  Mayo, 
indicate  the  same  views  of  function.  Division  of  the  ophthalmic 
or  of  the  superior  maxillary  induced  loss  of  sensibility  without  mus- 
cular paralysis,  leaving  only  such  an  impairment  of  the  motor  power 
as  destruction  of  the  sensitive  nerves  invariably  produces,  by  impair- 
ing the  power  of  exact  adjustment,  for  which  a  high  degree  of 
sensibility  is  necessary.  But  when  the  inferior  maxillary  nerve  was 
cut,  then  both  the  power  of  mastication  was  destroyed  on  the  same 
side  and  the  sensibility  of  the  lower  part  of  the  face  and  tongue  was 
lost.  If  the  nerve  was  divided  in  the  cranium,  the  whole  side  of  the 
face  and  forehead,  with  the  eyeball  and  nose,  became  insensible,  and 
the  muscles  of  mastication  were  paralyzed.  Irritants  might  then  be 
applied  to  the  eyeball  without  exciting  winking  or  causing  pain, 
and  strong  stimulants  might  be  introduced  into  the  nostrils  without 
creating  the  least  irritation.  When  the  trunk  of  the  nerve  within 
the  cranium  of  an  ass  was  irritated,  the  jaw  closed  with  a  snap 
from  the  excitation  of  the  motor  fibers,  which  are  distributed  to  the 
muscles  of  mastication. 

' '  '  The  conclusions  which  we  draw  from  anatomy  and  from  experi- 
ment are  confirmed  by  the  histories  of  cases  in  which  the  fifth  nerve 
had  been  diseased.  In  such  instances  we  may  observe  the  most 
marked  separation  of  the  motor  and  sensitive  power,  when  the  larger 
portion  only  or  the  two  superior  divisions  of  the  nerve  are  affected, 
and  we  find  both  motion  and  sensation  destroyed  when  the  whole 
trunk  of  the  nerve  is  involved  in  the  disease.  It  is  not  uncommon 
in  such  cases  to  find  the  eyeball  totally  insensible  to  every  kind  of 
stimulus,  the  nose  quite  unexcitable  by  the  fumes  of  ammonia  or  the 
most  pungent  vapors,  and  the  mucous  membrane  of  the  mouth  so 
insensible  to  the  contact  of  foreign  matters  that  a  morsel  of  food  will 
sometimes  remain  between  the  gum  and  the  cheek  until  it  has  be- 
come decomposed.  The  insensibility  of  the  eyeball  exposes  it  to 
the  permanent  contact  of  irritating  particles  of  dust,  etc.,  which 
excite  destructive  inflammation  of  its  textures.  The  whiskers  may 
be  pulled  forcibly  without  sensation.  The  muscles  of  mastication 
become  wasted  and  inert,  as  shown  by  the  distinct  depression  in  the 
regions  of  the  masseter  and  temporal  muscles,  but  the  superficial 
muscles,  on  which  the  play  of  the  features  depends,  preserve  their 
natural  condition. 

"  '  The  fifth  nerve  may,  therefore,  be  regarded  as  the  motor  nerve 
in  mastication,  and  the  sensitive  nerve  to  that  great  surface,  both  in- 
ternal and  external,  which  belongs  to  the  face  and  anterior  part  of 


158  DENTAL    PATHOLOGY   AND    PRACTICE. 

the  cranium.  From  its  great  size,  and  the  large  portion  of  the  me- 
dulla oblongata  with  which  it  is  connected,  it  may  excite  other  nerves 
which  are  implanted  in  that  center  near  to  it.  Thus  it  may  be  an 
excitor  to  the  portio  dura,  as  in  winking  ;  or  to  the  respiratory 
nerves,  as  in  dashing  cold  water  in  the  face  or  in  sneezing.  Its  lin- 
gual portion,  distributed  to  the  mucous  membrane  of  the  tongue,  is 
at  once  a  nerve  of  taste,  touch,  and  common  sensibility,  and  its  con- 
nection with  the  papillary  structure  of  the  red  parts  of  the  lips  consti- 
tutes it  a  pre-eminently  sensitive  nerve  of  touch  in  those  regions. 

' '  '  The  study  of  the  pathological  conditions  of  this  nerve  illustrates 
its  physiology  in  a  highly  interesting  manner.  In  the  dentition  of 
children,  whether  primary  or  secondary,  it  is  always  affected,  more  ' 
or  less  ;  and  in  excitable  states  of  the  nervous  centers  the  irritation 
of  it  consequent  upon  the  pressure  of  the  teeth  often  gives  rise  to 
convulsions,  the  brain  and  spinal  cord  being  irritated  ;  and  we  can 
often  trace  to  such  irritation,  whether  in  infancy  or  in  childhood,  the 
foundation  of  epileptic  seizures  in  subsequent  years.  Painful  affections 
of  the  face  (neuralgia)  have  their  seat  in  this  nerve  ;  tic  douloureux, 
for  example.  Many  of  the  instances  of  painful  affection  of  this  nerve 
or  of  branches  of  it  which  come  under  our  observation  are  well- 
marked  examples  of  refl^Nfd  sensation,  the  primary  irritation  being 
conveyed  to  the  center  by\nievyagus  or  the  sympathetic  from  the 
stomach  or  intestinal  canal.  No  one  of  these  is  so  common  as  the 
pain  over  the  brow  which  so  often  follows  derangement  of  stomach 
digestion,  and  which  may  frequently  be  instantaneously  removed  by 
taking  away  the  source  of  irritation,  as  by  neutralizing  free  acid  in 
the  stomach.  Frequently  also  the  branches  of  this  nerve,  in  greater 
or  less  number,  on  one  or  both  sides,  may,  according  to  the  humoral 
view,  form  a  focus  of  attraction  for  a  morbific  matter  generated  in  the 
blood,  in  persons  exposed  to  the  paludal  poison,  or  in  persons  of 
rheumatic  or  gouty  constitution  ;  in  these  cases,  as  in  most  others  of 
similar  pathology,  the  neuralgia  occurs  in  paroxysms  of  greater  or 
less  severity,  each  paroxysm  being  followed  by  a  period  of  conval- 
escence, which  lasts,  it  may  be  supposed,  until  the  morbid  matter 
has  been  again  accumulated  in  quantity  sufficient  to  induce  a  high 
degree  of  irritation  of  the  nerves.' 

"Fig.  61  shows  the  ganglion  of  Gasser,  its  three  branches,  its 
divisions  and  subdivisions,  and  their  connections  with  the  other 
nerves  ;  also  some  of  the  arteries  and  muscles  of  the  face  and  neck. 
"  Accessory  Parts. — «,  Portion  of  the  membrane  of  the  tympanum 
and  bones  of  the  ear.  b,  Glenoid  cavity,  c,  Section  of  orbicularis 
oris,  d.  Buccinator  traversed  by  the  parotid  duct.  <?,  Internal 
pterygoid  muscle,  f,  External  pterygoid  muscle,  cut  to  show  its 
relations  with  the  terminal  branches  of  the  inferior  maxillary  nerve 


FACIAL   NEURALGIA. 


159 


and  internal  pterygoid  muscle,  g,  Digastric  muscle,  h,  Section  of 
sterno-cleido-mastoideus  muscle. 

"  Vascular  System. — A,  External  carotid  artery.  B,  Facial 
artery.  C,  Temporal  artery.  D,  Internal  maxillary  artery,  situated 
in  front  of  the  terminal  branches  of  the  inferior  maxillary  nerve.  E, 
Its  dental  branch.      F,  The  middle  meningeal  artery. 

"  Nervous  System. — i,  The  ganglion  of  Gasser.  2,  The  ophthalmic 
nerve,  and  its  three  branches.  3,  Frontal  branch  ;  4,  Lachrymal  ; 
and  5,  Nasal.     6,  Ophthalmic  ganglion,  its  three  roots,   and  ciliary 


Fig.  61. 


'  &,  4    ,» 


h- 
19- 


branches.  7,  Superior  maxillary  nerve.  8,  Orbital  branch,  with  its 
three  divisions  ;  the  temporal  and  malar  are  cut  ;  the  lachrymal 
anastomoses  with  a  filament  of  the  same  name  from  the  ophthalmic. 
9,  Spheno-palatine  ganglion,  with  its  roots  of  sensation  given  off  from 
the  superior  maxillary.  10,  The  Vidian  nerve,  connecting  the  intu- 
mescentia  gangliformis  of  the  facial  with  the  spheno-palatine  ganglion, 
ir,  Palatine  nerves,  situated  in  the  palatine  canal.  12,  Junction  of 
the  spheno-palatine  ganglion  with  the  nerve-plexus  surrounding  the 
internal  maxillary  artery,  13,  Posterior  and  superior  dental  nerves, 
penetrating  the  superior  maxillary  bone.    14,  Spreading  of  the  infra- 


i6o 


DENTAL  PATHOLOGY  AND  PRACTICE. 


orbital  nerve  ;  it  anastomoses  with  the  facial  and  above  with  the 
nasal.  15,  Inferior  maxillary  nerve,  receiving  the  motor  portion  of 
the  fifth  pair.  16,  Superficial  auriculo-temporal  nerve ;  its  roots 
embrace  the  middle  meningeal  artery  ;  it  then  follows  the  neck  of  the 
condyle,  forming  loops  around  the  temporal  artery,  giving  anasto- 
motic branches  to  the  facial  and  ascending  branches,  which  are  here 
cut.  17,  Buccal  nerve,  anastomosing  with  the  facial ;  its  temporal 
branch  is  divided.  18,  Section  of  the  other  collateral  branches  of 
the  inferior  maxillary.  19,  Inferior  dental  nerve,  and  its  ramifica- 
tions to  the  roots  of  the  teeth.  20,  Mental  nerve,  its  termination  in 
the  mucous  membrane  of  the  lower  lip,  and  its  junction  with  the 
facial.  21,  Lingual,  passing  between  the  buccinator  and  the  ramus 
of  the  lower  jaw.  22,  Chorda  tympani,  running  between  the  handle 
of  the  malleus  and  the  crown  of  the  incus  ;  it  establishes  the  commu- 
nication between  the  lingual  and  facial.  23,  Portio  dura,  and  its 
divisions  into  cervico-facial  and  temporo- facial  branches. 

"  Fig.  62  shows  parts  of  the  fifth  pair  which  have  not  been  studied 


6 
20 


in  the  preceding  figure  ;  the  ganglion  of  Gasser  and  its  branches  are 
detached,  so  as  to  show  the  nerve-plexus  of  the  internal  carotid 
artery. 

'^Accessory  Parts. — a,   Superior  maxillary  bone,   from  which  the 


FACIAL   NEURALGIA.  l6l 

external  table  has  been  removed,  to  show  the  dental  plexus,  b, 
Cartilages  of  the  nose,  c,  Internal  view  of  the  tympanitic  cavity. 
d.  Internal  pterygoid  muscle  and  angle  of  the  jaw.  e,  Section  of 
the  buccinator  muscle.  _/,  Mylo-hyoid  muscle,  partly  detached  from 
the  inferior  maxilla,  g,  Portion  of  the  anterior  belly  of  the  digastric 
muscle.  ^,  Portion  of  the  sterno-cleido-mastoideus  muscle,  turned 
back. 

^^ Nervous  System. — i,  Ophthalmic  nerve,  divided.  2,  Superior 
maxillary  nerve,  divided  at  its  two  extremities.  3,  Spheno-palatine 
ganglion.  4,  Petrosal  and  carotid  filament  of  the  Vidian  nerve. 
This  last  runs  in  company  with  the  branches  of,  5,  the  external 
ocular  motor,  6,  the  nerve  of  Jacobson,  and  the  great  sympathetic, 
to  form  a  plexus,  and  sometimes  a  ganglion  (cavernous  or  carotid 
ganglion),  placed  on  the  first  bend  of  the  internal  carotid  artery.  7, 
Posterior  and  superior  dental  nerves,  forming,  with  8,  anterior  and 
superior  dental  nerves,  a  plexus  supplying  branches  to  the  teeth  and 
superior  maxillary  bone.  9,  Otic  ganglion  and  common  trunk 
(Vidian  nerve)  of  the  two  small  petrosal  nerves.  10,  Lingual  nerve. 
1 1 ,  Chorda  tympani.  12,  Submaxillary  ganglion  sending  off  branches 
and  roots  to  the  submaxillary  gland.  13,  Junction  between  the 
lingual  and  hypoglossal  nerves.  14,  Ganglion  or  sublingual  plexus. 
15,  Terminal  branches  of  the  lingual  nerve,  supplying  the  mucous 
membrane.  16,  16,  Inferior  dental  nerves.  17,  17,  Mylo-hyoid 
branch  to  the  mylo-hyoid  muscle  and  the  anterior  belly  of  the  digas- 
tric muscle.  18,  Section  of  the  mental  nerve.  19,  Incisive  nerve. 
20,  Ganglion  of  the  glosso-pharyngeal  nerve.  21,  Facial  nerve  in 
the  aqueduct  of  Fallopius.     22,  Hypoglossal  nerve. 

"Fig.  63,  Diagram  showing  the  connection  of  the  fifth  pair  with 
most  of  the  cranial  ganglia. 

'''Nervous  System. —  i.  Ganglion  of  Gasser,  with  its  roots  and 
branches.  2,  Ophthalmic  ganglion.  3,  Its  long  and  slender  root 
furnished  by  the  nasal  branch.  4,  Its  thick  and  short  root  emanating 
from  the  small  oblique  nerve,  branch  of  the  ocular  or  motores  oculo- 
rum.  5,  Its  vegetative  root  proceeding  from  the  plexus  which  sur- 
rounds the  internal  carotid  artery.  6,  Ciliary  nerves  traversing  the 
sclerotic  and  lying  between  it  and  the  choroid  coat,  and  joining  the 
ciliary  ganglion,  7.  8,  Spheno-palatine  ganglion.  9,  Its  nerves  of 
sensation  proceeding  from  the  superior  maxillary.  10,  Petrous  por- 
tion of  the  Vidian  nerve.  11,  Carotid  filament,  considered  as  its 
sympathetic  root.  12,  Naso-palatine  ganglion,  receiving  at  its  supe- 
rior angle  the  internal  spheno-palatine  nerve  (naso-palatine),  and  by 
its  inferior  angle  the  anterior  palatine  nerve.  13,  Otic  ganglion. 
14,  Small  superficial  petrosal  nerve  of  Arnold.  15,  Submaxillary 
ganglion  attached  to  the  lingual  nerve  by  its  roots  of  sensation,  and 


l62 


DENTAL   PATHOLOGY   AND    PRACTICE. 


giving  branches  to  the  submaxillary  gland,  of  which  a  portion  only 
is  preserved  here.     i6,   Sublingual  ganglion,  attached  also  to  the 

Fig.  63. 


!0      J 


ir- 

18- 


.•5  -l     G 


:.9 

-13 


14        \ 


15         115 


lingual  nerve,  and  distributed  to  the  sublingual  gland.  17,  Intumes- 
centia  gangliformis,  which  adheres  to  the  first  elbow  of  the  facial,  and 
gives  origin  to  the  great  superficial  petrosal.     18,  Cavernous  ganglion. 

Fig.  64. 


FACIAL   NEURALGIA.  1 63 

' '  Fig.  64,  Collateral  or  motor  branches  of  the  inferior  maxillary- 
nerve,  viewed  from  the  cranial  cavity. 

''Nervous  system. — i,  The  ganglion  of  Gasser,  and  its  large  root. 
2,  Inferior  maxillary  nerve  seen  in  the  foramen  ovale,  3,  Buccal 
nerve  passing  between  the  two  portions  of  the  external  pterygoid, 
and  giving  off,  at  the  moment  it  changes  its  direction,  4,  the  ante- 
rior deep  temporal  nerve.  5,  Masseteric  nerve,  which  winds  round 
the  insertion  of  the  external  pterygoid  in  the  condyle  of  the  jaw, 
giving  off,  6,  the  posterior  deep  temporal  nerve.  7,  Middle  deep 
temporal  nerve,  furnished  directly  from  the  inferior  maxillary 
nerve." 

It  will  be  observed  from  the  foregoing  beautiful  description  of  the 
fifth  nerve  that  not  only  may  nerves  of  general  sensation  of  the  face 
and  head  become  involved  in  dental  irritation,  but  that  those  of  the 
special  senses  of  sight,  hearing,  tasting,  and  smelling,  as  well  as  the 
motor  nerves  of  the  face,  and  the  sympathetic,  may  be  affected. 

It  is  often  remarked  that  the  fifth  nerve  is  the  most  sensitive  of  any 
in  the  human  body.  That  when  irritated  it  is  one  of  the  most  pain- 
ful and  productive  of  the  greatest  amount  of  suffering,  both  of  a 
local  and  general  nature,  I  think  will  hardly  be  disputed. 

Let  us  study  for  a  few  moments  its  liability  to  disturbance  in  and 
around  the  teeth,  from  which,  in  my  judgment,  based  upon  observa- 
tion through  many  years  of  active  practice,  arise  at  least  nine-tenths 
of  the  cases  of  facial  neuralgia  the  physician  is  called  upon  to  treat ; 
besides  many  troubles  of  the  eye  and  ear,  and  some  of  a  more 
general  character. 

It  is  well  settled  that  the  teeth  are  provided  with  living  matter, 
distributed  throughout  the  dentine  and  cementum  quite  freely,  but 
less  so  in  the  enamel.  The  last,  indeed,  has  so  small  a  quantity  that 
it  is  seldom  if  ever  susceptible  to  irritation  sufficient  to  produce  pain  ; 
while  dentine  or  cementum,  if  exposed  to  the  acids  produced  by  the 
fermentation  of  particles  of  food,  will,  without  any  perceptible  caries, 
produce  a  diffusive  neuralgic  pain  of  great  persistence,  which  is 
relieved  only  by  the  use  of  alkalies.  A  carious  cavity  in  either 
dentine  or  cementum,  no  matter  how  slight,  is  irritated  under  the  in- 
fluence of  acids  to  such  an  extent  that  persistent  facial  neuralgia  is 
often  the  result. 

Cases  of  both  descriptions  are  frequently  met  with  in  the  mouths 
of  women  during  gestation  and  lactation.  Rinsing  the  mouth  every 
half-hour  with  a  solution  of  bicarb,  soda  and  water  (^jss  toj^viij)  will 
give  almost  immediate  relief,  and  so  long  as  a  neutral  or  alkaline 
condition  of  the  fluids  of  the  mouth  is  maintained,  quiet  will  reign. 


164  DENTAL    PATHOLOGY   AND    PRACTICE. 

This  condition  continues  only  while  the  alkaline  wash  is  being  used, 
which  suggests  at  least  the  more  or  less  constant  employment  of 
such  a  wash  for  the  mouth  until  the  portions  of  teeth  so  diseased  can 
be  removed  and  replaced  by  an  indestructible  filling.  In  many  cases 
the  filling  of  the  teeth  is  not  advisable  during  gestation  ;  in  fact,  I 
should  advise  that  it  never  be  done  except  in  a  temporary  way  during 
that  period.  This  subject  is  treated  upon  more  fully  in  another 
chapter. 

Exposure  of  the  pulp  in  a  tooth,  from  any  cause,  brings  that  most 
sensitive  organ  directly  in  contact  with  irritating  substances.  Such 
substances  I  am  inclined  to  believe,  however,  must  always  be  of  an 
acid  nature  to  cause  sufficient  disturbance  to  produce  pain.  I  reach 
this  conclusion  from  the  fact  that  when,  as  often  occurs,  the  pulps  of 
teeth  are  exposed  in  localities  where  particles  of  food  cannot  lodge 
upon  or  around  them,  no  acid  is  produced  locally,  and  no  irritation  of 
the  pulp  seems  to  exist.  For  example,  I  have  now  under  treatment  a 
boy,  some  ten  years  of  age,  who  had  the  misfortune  to  break  off  one 
of  his  upper  central  incisors  through  the  larger  portion  of  the  pulp- 
chamber,  leaving  the  pulp  bare  nearly  a  sixteenth  of  an  inch,  some 
twelve  months  since.  For  fear  of  doing  further  harm,  I  have  not 
attempted  to  remove  or  destroy  the  pulp.  No  pain  whatever  has 
been  experienced  by  the  boy  since  the  break,  simply  because  the 
parts  are  being  constantly  cleansed  by  eating,  drinking,  and  the 
movements  of  the  tongue  and  lip. 

Neuralgia  from  irritation  of  an  exposed  pulp  in  a  tooth  is  relieved 
only  by  local  treatment.  Sometimes,  however,  patients  so  affected 
are  tresited  g-enera//y  by  the  medical  practitioner  for  a  long  period, 
and  the  patient  finally  gets  relief  when  the  sick  pulp  dies.  A  brilliant 
success  is  thus  recorded  in  the  physician's  hands  by  the  use  of  per- 
haps an  old  but  more  probably  some  new  remedy.  The  proper 
treatment  in  such  cases  will  be  found  in  the  chapter  upon  ' '  Treatment 
of  Exposed  Pulps." 

Pulp- Stones  (calcific  deposits  in  the  substance  of  pulps). — This  is 
a  condition  much  more  prevalent  than  is  commonly  supposed, — in 
many  cases,  however,  in  a  mild  form.  In  other  words,  the  deposits 
produce  no  special  irritation.  In  the  examination  of  pulps  of  teeth 
microscopically,  from  the  mouths  of  a  large  number  of  persons, 
both  young  and  old,  Bodecker  found  such  deposits  much  more  com- 
mon than  he  anticipated  ;  even  in  pulps  of  teeth  taken  from  the 
mouths  of  children  as  young  as  twelve  years,  many  such  deposits 
were  discovered. 

The  cause  of  these  collections  has  been,  and  still  is,  somewhat  of  a 
mystery,  although  it  has  seemed  to  me  that  they  are  due  primarily 
to  an  embolus,  which  may  be  a  uric-acid  crystal,  or  some  other  sub- 


FACIAL   NEURALGIA.  165 

stance  brought  by  the  blood-current,  too  large  to  pass  through  the 
•delicate  capillaries  of  the  pulp.  This  obstruction  forms  a  nucleus, 
and  the  lime-salts,  which  are  constantly  being  carried  to  the  tooth 
through  the  pulp  for  building  and  repair  purposes,  or  for  the  formation 
of  secondary  dentine,  lodge  around  it ;  and  thus  a  constant  accretion 
takes  place,  until,  in  very  many  instances,  the  pulp-chamber  or  the 
canal  becomes  so  nearly  filled  with  the  mass  that  it  impinges  upon  the 
delicate  nerves  of  the  organ,  by  pressing  them  between  it  and  the 
opposite  side  of  the  canal  or  chamber.  Through  the  irritation  thus 
produced  a  long-continued  neuralgia  is  often  endured  before  relief  is 
obtained.  The  pain  sometimes,  however,  is  at  once  located  in  the 
offending  tooth,  when  it  is  very  acute,  although  usually  intermittent. 

To  diagnosticate  a  case  of  this  kind  is  often  very  troublesome. 
First,  a  careful  examination  should  be  made  as  to  the  external  condi- 
tion of  the  suspected  tooth.  If  it  is  found  apparently  sound,  and  no 
obvious  cause  for  such  lancinating  pain  as  the  patient  complains  of  can 
be  discovered,  a  few  drops  of  ice-water  thrown  upon  it  with  a  syringe 
will,  if  the  tooth  is  really  the  offender,  intensify  the  pain  to  a  greater 
extent  than  when  thrown  upon  a  neighboring  tooth.  A  slight  perios- 
teal irritation  also  is  usually  discovered,  if  the  tooth  is  tapped  with  a 
very  light  instrument  or  with  the  finger-nail. 

When  the  diagnosis  is  made  out  satisfactorily,  only  two  courses  of 
treatment  which  promise  relief  are  open  :  one  is  the  extraction  of  the 
tooth  ;  the  other,  the  destruction  of  the  pulp.  The  latter  will  be  a 
long  and  tedious  operation,  with  more  or  less  continual  pain,  until  the 
pulp  is  deadened  beyond  the  point  of  irritation.  If  the  tooth  is  worth 
the  trouble  to  the  patient,  and  if  he  or  she  will  exercise  due  patience, 
it  may  be  saved  for  years  of  usefulness  by  this  mode  of  treatment. 
As  soon  as  the  pulp  yields  to  the  death-dealing  application,  the  entire 
•dead  substance  must  be  removed  and  the  canals  and  tooth  immediately 
filled.     Extraction  of  the  tooth  gives  almost  immediate  relief. 

Another  prolific  cause  of  facial  neuralgia  is  what  is  termed  malpo- 
sitioned  teeth.  These  are  most  frequently  cuspids,  bicuspids,  or  third 
molars  (wisdom-teeth).  For  some  unexplained  reason,  the  formation 
(development)  of  these  teeth  occasionally  takes  place  in  a  wrong  direc- 
tion. The  cuspids  (more  usually  the  upper)  and  bicuspids,  both 
tipper  and  lower,  may  be  formed  or  developed  in  a  horizontal  in- 
stead of  a  vertical  position.  Through  the  effort  of  nature  to  get  rid 
of  what,  in  its  irregular  position,  amounts  to  a  foreign  body,  the 
tooth  is  propelled  slowly  forward,  and  as  the  crown  comes  in  con- 
tact with  the  periosteum  covering  the  bone,  the  forward  movement 
being  so  slow,  the  tooth  remains  unerupted  sometimes  for  years. 
The  periosteal  membrane  being  highly  vascular,  and  thickly  trav- 
ersed by  nei've-filaments,  soon  becomes  the  seat  of  a  lively  neuralgia, 


1 66  DENTAL  PATHOLOGY  AND  PRACTICE. 

which  frequently  continues  many  years  before  its  cause  is  discov- 
ered. When  it  is  discovered  and  the  imbedded  tooth  is  removed, 
the  nerves  of  the  face  are  often  found  to  have  become  so  demoraHzed 
through  the  long-continued  irritation  that  the  neuralgia  persists,  re- 
fusing to  be  at  once  relieved.  In  such  cases,  however,  time  and 
tonics,  or  change  of  climate,  will  eventually  effect  a  cure.  I  have  in 
mind  in  my  practice  as  I  am  writing  several  patients  who  suffered 
from  five  to  sixteen  years  with  constant  neuralgia,  baffling  the  skill  of 
our  best  general  practitioners,  many  of  whom  have  had  trials  with  the 
same  case,  without  giving  the  slightest  relief,  which  was  obtained  only 
after  the  discovery  and  removal  of  an  offending  tooth. 

Impacted  third  molars  (wisdom-teeth),  especially  of  the  lower  jaw, 
are  often  the  cause  of  protracted  and  severe  facial  neuralgia.  Fre- 
quently, in  the  development  of  these  teeth,  they  are  set  in  an  oblique 
instead  of  a  vertical  position,  so  that,  as  they  advance  in  their  sock- 
ets, the  crowns  come  in  contact  with  the  periosteum  upon  the  neck 
of  the  second  molar,  producing  a  persistent  irritation  which  is  dif- 
fused ;over  the  side  of  the  face  and  head,  causing  untold  agony 
quite  often  through  a  long  period  before  the  cause  is  discovered. 
The  location  of  the  third  molar,  its  peculiar  position  when  thus 
lodged,  and  its  shape,  render  it  one  of  the  most  difficult  teeth  to 
extract  under  such  circumstances,  and  the  neuralgia  which  its  mal- 
position sets  up  one  of  the  most  troublesome  to  treat  in  the  long  list 
of  these  maladies. 

Relief  may  be  obtained  by  removing  either  the  offending  tooth 
itself  or  the  second  molar  against  which  it  is  pressing.  No  other 
treatment  will  avail.  The  extraction  of  the  former  being,  in  many 
cases,  impracticable,  the  latter  must  be  sacrificed. 

Hyperostosis  of  roots  of  teeth  is  also  a  fruitful  source  of  facial  neu- 
ralgia. This  is,  as  its  name  implies,  an  extraordinary  growth  of  the 
cementum  upon  the  roots  of  teeth,  the  result  of  imperfect  formation 
(see  Chapter  XVIII)  or  long-continued  irritation  of  the  periosteum 
covering  the  root.  The  function  of  this  membrane  is  to  select  from 
the  blood,  and  supply  where  needed,  lime-salts  for  growth  or  repair  of 
bone-tissue.  When  the  membrane  is  irritated,  this  function  is  stimu- 
lated. The  irritation  is  usually  from  an  exposed  or  nearly  exposed 
pulp,  which  passes  through  the  canal  and  affects  the  periosteum  at  and 
around  the  apex  of  the  root,  producing  what  may  be  termed  forma- 
tive irritability, — i.e.,  the  periosteum  is  continuously  irritated  suffi- 
ciently to  excite  its  functional  activity.  The  result  is  a  growth  or 
thickening  of  the  cementum  by  a  constant  deposition  of  lime-salts. 
As  the  root  enlarges,  absorption  of  the  alveolus  around  it  must  take 
place,  to  make  room  for  the  extra-sized  root.  This  absorption 
sooner  or  later  becomes  tardy  in  its  work  of  making  roorn,  and  pres- 


FACIAL    NEURALGIA.  167 

sure  upon  the  nerves  of  the  periosteum  is  produced  in  consequence. 
Persistent  neuralgia  naturally  follows.  In  many  cases  this  goes  on 
for  years  before  the  true  cause  is  ascertained. 

I  do  not  wish  to  be  understood  as  saying  that  irritation  of  the  pulp 
of  a  tooth  is  always  essential  to  the  production  of  hyperostosis  of 
roots.  I  have  many  specimens  in  my  collection, — which  by  the  way 
is  very  extensive  in  this  particular  line, — where  the  pulps  were  not 
exposed,  nor  the  teeth  even  decayed,  but  with  very  marked  enlarge- 
ment of  their  roots,  the  teeth  having  been  extracted  to  relieve  neuralgia. 
Specific  disease,  whether  contracted  or  inherited,  imperfect  develop- 
ment, or,  as  some  believe,  a  gouty  diathesis,  often  produces  localized 
irritation  of  the  periosteum  around  the  roots  of  teeth,  which  results  in 
their  enlargement. 

The  diagnosis  of  hyperostosis,  in  many  cases,  is  somewhat  obscure, 
and  difificult  of  determination.  However,  there  are  certain  points 
which  should  always  be  borne  in  mind  :  First,  a  somewhat  enlarged 
condition  or  bulging  of  the  alveolus  over  roots  of  the  affected  tooth  ; 
and,  second,  a  slight  periosteal  tenderness  upon  percussion  with  a 
light  instrument :  these,  taken  in  connection  with  the  localizing  of 
the  seat  of  pain,  are  usually  sufficient  to  base  a  diagnosis  upon.  The 
removal  of  the  tooth  or  teeth  so  affected  is  the  only  remedy. 

Tartar  upon  the  roots  of  teeth  (seruminal  deposit — pyorrhea  alveo- 
laris,  by  different  authors)  is  a  seldom-failing  source  of  neuralgic 
pains,  which  in  many  instances  are  not  confined  to  the  face  and  head, 
but  are  distributed  through  the  neck,  chest,  shoulders,  and  back, 
with  a  persistency  quite  phenomenal.  This  is  not  to  be  wondered  at, 
however,  when  it  is  taken  into  account  that  the  thousand  and  one 
nerve-filaments  in  the  gum  and  periosteum  are  under  constant  inflam- 
mation in  all  such  cases. 

The  remedy  is  to  thoroughly  remove  the  irritant,  paint  the  gums 
with  tincture  of  iodin,  and  rinse  the  mouth  ten  or  a  dozen  times  a 
day,  for  two  or  three  days,  with  warm  salt  water,  or  with  a  saturated 
solution  of  chlorate  of  potash  in  water.  Should  the  teeth  from 
which  tartar  has  been  removed  be  sensitive  to  cold,  heat,  or  acids, 
as  is  quite  frequently  the  case,  a  solution  of  bicarbonate  of  soda  and 
water,  5j  to  5viij,  to  which  is  added  three  grains  of  salicylic  acid,  may 
be  used  as  a  wash  several  times  a  day  to  great  advantage.  Under  this 
treatment  the  gums  heal,  the  sensitiveness  of  the  teeth  disappears, 
and  the  distressing  neuralgia  ceases. 

Pulpless  teeth  are  among  the  many  sources  of  facial  neuralgia. 
This  is  easily  appreciated  and  understood  in  cases  where  the  dead 
and  putrefying  pulp  is  allowed  to  remain  in  the  pulp-chamber  and 
canals  of  a  tooth  ;  but  when  the  canals  have  been  cleansed  and  filled 
with,  supposedly,  the  proper  material,  it  is  sometimes  not  so  readily 


l68  DENTAL    PATHOLOGY  AND    PRACTICE. 

accounted  for.  The  proper  cleansing  of  the  canals  is  of  primary 
importance.  This  involves  not  only  the  removal  of  the  dead  and 
putrefying  material  from  them,  but  all  the  products  of  putrefaction 
(ptomaines)  must  be  eliminated  in  order  that  a  recurrence  of  the 
process  or  disturbance  may  be  avoided.  In  order  to  accomplish  this 
in  the  most  satisfactory  manner,  aqueous  solutions  for  irrigating  the 
canals  are  forced  into  them  with  considerable  energy.  Oily  sub- 
stances, such  as  creasote  or  any  of  the  essential  oils,  adhere  to  the 
walls  of  the  canals  and  at  the  apex,  and  retain  either  portions  of  the 
dead  pulp  or  ptomaines,  or  both,  with  them.  Absorption  of  the  oil 
subsequently  takes  place,  when  the  poison  is  left  to  again  assert 
itself  upon  the  slightest  provocation,  which  is  usually  a  hard  or 
wrenching  bite  upon  the  affected  tooth,  or  a  slight  cold.  Any- 
thing, in  fact,  which  will  determine  an  unusual  flow  of  blood  to  the 
parts  will,  under  such  conditions,  develop  periosteal  irritation.  This 
is  probably  brought  about  by  the  extra  amount  of  blood-supply, 
which  develops  and  diffuses  through  the  periosteum  an  increased 
quantity  of  the  poison.  The  filling-material  for  pulp-canals  should 
always  be  of  a  plastic  nature,  as  neither  gold  nor  tin  can  be  packed 
into  them  solidly,  and  such  fillings  leave  the  openings  of  the  canaliculi 
unstopped,  and  are  always  porous.  The  interstices  become  filled 
with  poisonous  gases  from  putrefaction  of  the  contents  of  the  canal- 
iculi, the  odor  of  which  is  always  very  much  in  evidence  when  such 
a  filling  is  disturbed. 

We  have  for  treatment  of  neuralgia  arising  from  periostitis,  from 
this  cause,  two  courses  which  may  be  followed.  One  is  the  extraction 
of  the  affected  tooth,  which  (if  the  tooth  be  of  no  special  use)  would 
be  considered  good  practice.  If,  however,  the  tooth  can  be  made 
useful  by  relieving  its  condition,  that  should  in  all  cases  be  persistently 
and  faithfully  tried.  (For  the  treatment  and  filling  of  pulp-canals, 
see  chapter  on  "Treatment  of  Pulpless  Teeth.")  First,  its  canal  or 
canals  should  be  properly  filled.  Then  a  powerful  counter-irritant 
should  be  applied  to  the  gum  over  it,  the  application  being  repeated 
at  intervals  of  three  or  four  hours  until  relief  is  obtained.  Usually 
three  or  four  applications  will  suffice  in  the  severest  case.  The 
remedy  which  is  most  lasting  in  its  effects,  and  the  most  reliable,  is 
equal  parts  of  concentrated  tincture  of  aconite-root  and  tincture  of 
iodin  applied  by  means  of  a  swab  made  of  a  wisp  of  cotton  wound 
upon  a  wooden  toothpick.  Capsicum  plasters,  cantharidal  collodion, 
and  many  other  substances  are  also  used  to  advantage. 

Gravitation  of  upper  teeth,  after  the  loss  of  their  antagonists  in  the 
lower  jaw,  will  occasionally  be  found  such  a  source  of  periosteal  irri- 
tation that  severe  facial  neuralgia  will  be  produced.  In  such  cases, 
antagonizing  teeth  must  be  supplied  or  the  affected  teeth  extracted. 


HYPEROSTOSIS    OF    ROOTS    OF   TEETH.  169 

In  facial  neuralgia  the  origin  of  which  is  not  readily  traceable,  the 
following  remedies  applied  to  the  gums  and  face  will  be  found  of 
excellent  service  : 

R — Oil  wintergreen,  -x 

Oil  peppermint,  aa  5  ij ;  ^  Sedative.     Anesthetic. 
Sulph.  ether,  J  ss.  J 

M. 

B — Con.  tr.  aconite  root,  1 

Chloroform,  I        ,    .  „         ,      . 

,,,,--  .T  •  r  Sedative.     Anesthetic. 

Alcohol,  aa  ^j  ; 

Sol.  morph.   (Maj.),  gtt.  xij.  J 

M. 

R-Menthol,  3  ij  1 1  Sedative. 
Alcohol,  gj.     J 
M. 

R — Menthol,  3J  ;         -v 

Chloroform,  3  x  ;  >■  Sedative.     Anesthetic. 
Ether,  ^xv.     M.  J 

Constitutional  Remedies. 

R — Croton  chloral  hydrate,  oU! 
Glycerin,  ^  ij  ; 
Water,  q.  s.  ^  iv.      M. 
Sig. — A  teaspoonful  three  times  a  day. 

R — Quinin  sulph.,  ^ij  ; 
Morph.  sulph.,  gr.  iij  ; 
Strychnin  sulph.,  gr.  ij  ; 
Arsenious  acid,  gr.  iij  ; 
Ex.  aconit.,  gr.  xxx.     M. 
F. — Pills,  div.  No.  LX.     One  three  times  a  day. 


CHAPTER   XVIII. 

HYPEROSTOSIS   OF   ROOTS   OF  TEETH.* 

Under  the  term  "  hyperostosis"  I  propose  to  consider  all  the  forms 
of  pathological  new  growths  of  cementum,  including  what  authors  are 
wont  to  term  osteoma,  exostosis,  hypertrophy  of  the  cement,  etc. 

As  to  the  causes  of  this  not  very  infrequent  disease,  the  following 
may  be  enumerated  : 

*  Abbott,  Dental  Cosmos,  1SS6. 


lyo  DENTAL    PATHOLOGY   AND    PRACTICE. 

A.  Direct  irritation  of  the  pericementum  through  sHght  long- 
standing caries  of  the  crown  or  neck  ;  or,  exposure  of  the  pulp,, 
mainly  the  result  of  caries. 

B.  Localized  irritation  of  the  pericementum  of  constitutional  origin, 
as  from  gout  or  syphilis. 

C.  Irritation  of  the  pericementum  of  upper  teeth  after  the  removal 
of  their  antagonizing  teeth  of  the  lower  jaw,  the  result  of  or  induced 
by  gravitation. 

Obviously,  irritation  of  the  pericementum  is  considered  by  all 
authors  as  the  cause  of  outgrowths  of  cementum. 

All  tumors  are  considered  as  the  result  of  a  chronic  irritation  of 
the  mother  tissue  ;  not  sufficiently  intense  to  produce  symptoms  of 
inflammation,  with  its  typical  termination  in  hypertrophy,  or,  should 
suppuration  have  preceded,  in  cicatrization.  Tumors  are  unlimited 
growths,  caused  probably  by  a  constant  local  irritation,  first  of  the 
mother  tissue,  and  later  on  of  the  already  formed  tumor  itself 
Cohnheim  proposed  the  theory  that  "  all  tumors  are  the  result  of  a 
misplacement  of  embryonal  germs."  Unquestionably  such  a  mis- 
placement may  occur,  but  in  many  instances  it  either  is  not  traceable, 
or  the  embryonal  tissues  may  be  found  misplaced  in  normal  tissues 
without  ever  having  given  rise  to  the  formation  of  a  tumor.  That  a 
chronic  irritation  of  the  pericementum,  whatever  the  cause  may  be, 
may  result  in  a  new  formation  of  cementum,  nobody  will  doubt ;  nay, 
it  has  been  clearly  proven  by  Bodecker  that  a  circumscribed  hyper- 
ostosis of  the  cementum  may  arise  from  chronic  pericementitis.  The 
question,  however,  is,  can  a  diffiised  enlargement  of  the  cementum 
occur  in  consequence  of  pericementitis,  either  of  a  local  or  constitu- 
tional origin,  after  the  cementum  has  once  been  fully  formed  ?  This 
question  I  feel  constrained  to  answer  in  the  negative,  and  I  base  my 
opinions  upon  microscopical  studies  of  such  tumors.  My  conviction 
is  that  hyperostosis  of  cementum  of  a  diffiised  character  is  in  most 
instances  a  fetal  malformation. 

If  a  carious  tooth  be  extracted,  and  the  roots  be  found  in  a  hyper- 
plastic condition,  the  first  impression,  of  course,  would  be  that 
inflammation  of  the  pulp  had  led  to  pericementitis,  and  the  latter 
to  hyperostosis  of  the  roots.  This  in  some  instances  may  be 
the  case,  more  especially  when  the  process  of  caries  has  attacked 
a  lateral  surface  of  the  crown  or  the  neck  of  a  molar,  and  the  root  or 
roots  nearest  to  the  point  of  irritation  of  the  pulp  are  found  to  be 
enlarged  ;  but  if  all  the  roots  of  a  molar  are  uniformly  enlarged,  or 
fused  together,  we  hardly  feel  justified  in  stating  that  caries  was  the 
primary  and  hyperostosis  of  the  roots  the  secondary  cause,  or  the 
result  of  such  a  primary  cause  ;  for  it  is  possible  that  the  hyperplasia 
of  the  roots  has  been  present  long  before  the  caries  made  its  appear- 


HYPEROSTOSIS    OF    ROOTS    OF   TEETH.  I71 

ance.  The  latter  assumption  becomes  almost  a  certainty  when,  upon 
grinding  such  teeth  for  microscopical  research,  we  find  either  that  the 
caries  has  not  penetrated  sufficiently  deep  to  cause  inflammation  of 
the  pulp,  or  that  the  dentine  is  in  a  condition  which  could  not  be 
the  result  of  simple  "eburnitis,"  but  can  have  been  the  result  only 
of  a  malformation  at  the  beginning  of  its  growth  in  fetal  life. 

After  a  careful  study  of  a  large  number  of  specimens  of  hyperos- 
tosis, I  feel  entitled  to  the  statement  that  such  teeth  were  sound  and 
their  pulps  alive  long  after  the  bony  growth  had  formed. 

Whenever  a  tooth  is  deprived  of  its  nourishment  from  the  pulp,  I 
doubt  the  possibility  of  an  osseous  new  formation  upon  the  cementum  ; 
and,  further,  I  believe  that  should  such  a  new  formation  have  existed 
previously,  its  growth  would  undoubtedly  cease  the  moment  the  life 
of  the  pulp  was  gone.  Should  a  dentist  extract  a  sound-looking  tooth 
to  relieve  excessive  pericementitis,  or  neuralgia  suspected  to  arise  from 
pericementitis,  and  find  the  root  or  roots  considerably  enlarged,  he 
would  hardly  be  justified  in  concluding  that  the  pericementitis  and 
neuralgia  had  caused  the  growth  upon  the  roots  ;  but,  on  the  contrary, 
he  would  naturally  conclude  that  the  growth  had  been  the  primary 
and  the  pericementitis  and  neuralgia  the  secondary  features  of  the 
disease.  If  a  large  number  of  sound-looking  teeth  be  removed  from 
the  same  person's  upper  jaw,  for  instance,  to  relieve  neuralgia,  the 
roots  of  all  of  which  are  found  to  be  considerably  enlarged,  we  con- 
clude that  these  roots  were  malformed  at  the  earliest  stage  of  their 
development.  I  have  in  my  possession  six  upper  molars,  all  removed 
from  the  same  person's  mouth,  to  relieve  neuralgia,  the  roots  of  all  of 
which  are  more  or  less  enlarged  ;  three  of  them  have  no  decay  what- 
ever in  their  crowns,  and  the  other  three  are  but  slightly  affected. 
At  the  time  of  birth  only  the  crowns  of  the  temporary  teeth  are  found 
to  have  been  formed,  and  nothing  is  known  as  to  the  exact  period  of 
beginning  of  the  formation  of  cementum  upon  the  roots  ;  probably  it 
is  during  the  first  year  of  extra-uterine  life,  the  process  beginning 
upon  the  permanent  teeth  several  years  later. 

Cementum  being  identical  in  its  construction  with  bone-tissue,  we 
are  safe  in  concluding  that  their  development  is  likewise  identical. 
Bone,  the  same  as  any  other  tissue,  originates  or  is  built  from  med- 
ullary or  embryonic  tissue.  It  makes  no  difference  whether  carti- 
lage is  formed  first,  as  in  the  lower  jaw-bone,  or  fibrous  connective 
tissue,  as  in  the  flat  skull  bones  ;  the  changes  in  order  to  produce 
bone  are  the  same — each  is  first  converted  into  medullary  or  embry- 
onic tissue,  from  which  the  bone  proper  is  formed.  Some  of  the 
older  authors  (Tomes,  Shelly,  and  others)  adhere  to  the  theory  that 
medullary  corpuscles  (osteal  cells)  ' '  secrete  or  accumulate  about 
them  an  outer  investment  of  basis-substance,  and  afterward,  being 


172  DENTAL   PATHOLOGY   AND    PRACTICE. 

hollowed  out,  form  the  lacunae,  while  the  canaliculi  are  made  on  the 
plan  of  pore-canals  of  plants."  To-day  we  know  that  the  lacunae 
contain  living  protoplasm,  the  so-called  bone-corpuscles,  and  the 
canaliculi  hold  for  tenants  delicate  offshoots  of  the  bone-corpuscles, — 
i.e.,  fibers  of  living  matter.  To-day  we  also  know  that  the  basis- 
substance  arises  from  medullary  corpuscles,  the  same  as  the  bone- 
corpuscles  themselves.  The  theory  of  secretion  of  intercellular  sub- 
stance is  a  theory  of  the  past.  All  good  and  reliable  observers  agree 
that  only  one  portion  of  the  protoplasm  is  transformed  into  basis- 
substance,— viz,  the  lifeless  liquid,  which  changes  into  a  solid  glue- 
yielding  mass,  which  forms  the  matrix  and  is  the  seat  of  infiltration 
of  lime-salts,  the  living  protoplasm  remaining  unaltered  in  the  bone- 
corpuscles,  and  the  liviyig  portion  of  their  offshoots  is  preserved  in 
the  basis- substance  within  the  canaliculi.  No  growth  of  any  tissue  is 
possible  without  its  being  first  partially  reduced  to  medullary  ele- 
ments. An  augmentation  of  the  cementum  is  impossible  without  a 
preceding  augmentation  of  the  medullary  tissue,  which  again  is  caused 
by  increased  nutrition,  or,  as  it  is  generally  expressed,  an  irritation. 
Bodecker  has  demonstrated  that  in  normal  cement  the  lacunae  con- 
tain protoplasm,  a  portion  of  which  is  living  matter,  and  that  the 
entire  basis-substance  is  traversed  by  a  delicate  reticulum, — far  more 
delicate,  indeed,  than  previous  observers  have  thought  canaliculi  to 
exist.  This  reticulum  contains  the  threads  of  living  matter  in  a 
cobweb  arrangement.  Thus,  it  was  proven  that  the  cementum  is 
not  an  inert  mass,  a  deposition  of  lime-salts,  with  hollow  lacunae  and 
canaliculi. 

I  propose  to  show  that  cementum,  in  a  pathological  (hyperplastic) 
condition,  is  endowed  with  properties  of  life  the  same  as  in  its  normal 
state.  Thus  it  becomes  explicable  that  hyperplastic  cementum  itself 
may  become  the  subject  of  pathological  processes,  particularly  of 
inflammation.  Hyperplastic  cementum  may  and  often  does  become 
partially  destroyed  by  cementitis  and  transformed  into  medullary 
tissue,  from  which,  evidently,  an  additional  new  growth  of  cementum 
may  start. 

It  is  only  the  knowledge  that  cementum  is  a  living  tissue  all  through 
that  enables  us  to  understand  the  process  of  its  development,  its 
growth,  its  enlargement,  its  destruction,  and  its  re-formation. 

Since  the  beginning  of  the  present  century  a  good  many  reliable 
observers  have  described  and  depicted  anomalous  teeth  with  hyper- 
ostosis in  varying  degrees  of  development.  Some  of  these  illustra- 
tions are  striking  examples  of  the  excessive  growths  to  which  cemen- 
tum may  attain,  and  still  be  tolerated  by  the  sufferer.  All  observers, 
and  clinicians  generally,  I  think,  agree  that  this  disease  attacks  bi- 
cuspids and  molars  only,  incisors  and  cuspids  appearing  to  be  exempt ; 


HYPEROSTOSIS    OF    ROOTS    OF   TEETH.  173 

and,  again,  that  the  teeth  of  the  upper  jaw  are  more  frequently  affected 
than  those  of  the  lower. 

Facial  neuralgia  of  the  most  severe  and  unyielding  character  is 
frequently  caused  by  these  malformations.  At  the  same  time  the 
symptoms  which  point  to  a  diagnosis  of  hyperostosis  of  the  roots  are 
not  very  marked.  When  observable  at  all,  however,  they  consist  of 
a  slight  continued  uneasiness  in  the  jaw  (as  sometimes  expressed  by 
a  patient,  "  I  can't  call  it  real  pain,  but  I  am  constantly  aware  that  I 
have  a  tooth  in  that  locality").  It  is  akin  to  pain,  with  slight  sore- 
ness of  the  tooth  or  teeth  upon  biting,  while  excessive  pressure  upon 
it  in  any  direction  is  productive  of  quite  severe  and  prolonged  pain. 
Eventually  the  soreness  becomes  more  marked, — the  pain  being  con- 
stant or  intermittent, — and  finally  terminates  in  possibly  an  abscess, 
severe  mental  derangement,  or  the  removal  of  the  tooth  as  a  cure. 

It  is  not  infrequently  the  case  that  a  patient  suffering  from  neu- 
ralgia applies  to  a  dentist  to  have  a  certain  tooth  extracted  for  relief, 
the  case  being  to  the  dentist  so  obscure  that  he  takes  the  patient's 
word  for  it,  and  removes  the  tooth  ;  but  to  his  disgust  the  patient, 
after  a  few  moments,  turns  to  him  and  says,  "Why,  doctor,  that 
isn't  the  tooth  ;  the  pain  is  just  as  bad  as  it  was  before  you  took 
it  out. ' '  This  operation  is  repeated  over  and  over  again  with  the 
same  result,  until  finally,  perhaps,  the  last  tooth  in  the  jaw  when 
taken  out  reveals  the  cause  of  this  long  suffering,  in  an  enlarged 
root  or  roots  from  hyperostosis.  A  peculiar  feature  in  these  cases 
is  the  long-continued  and  most  distressing  pain  that  follows  such 
extractions,  relief  coming  but  very  slowly. 

As  custodian  of  that  portion  of  the  museum  of  the  New  York 
College  of  Dentistry  which  pertains  to  my  department,  I  have  come 
into  possession  of  a  large  number  of  teeth  exhibiting  hyperostosis  of 
the  roots,  and  this  comparatively  large  collection  prompts  me  to  try  to 
classify  the  different  varieties  as  they  occur  to  me.  I  will  here  add 
that  about  one-third  of  these  teeth  are  sound  or  very  nearly  so. 
Previous  authors  have  simply  described  different  forms,  more  or  less 
striking,  without  observing  any  system  in  the  arrangement. 

I. — Circumscribed  Hyperostosis. 

Under  this  title  are  included  osteoma  and  exostosis  of  the  authors, 
which  are  characterized  by  an  outgrowth  of  bone-tissue  from  the 
cementum,  of  a  limited  size,  varying  from  that  recognizable  with  the 
microscope  only  to  that  of  a  lentil  or  a  pea.  Their  surfaces  usually 
present  a  nodular  appearance,  and  sometimes  they  are  adjacent  to 
newly-formed  cancellous  structure  of  bone,  evidently  caused  by  oste- 
itis of  the  socket.     I  would  subdivide  this  group  into  : 


174 


DENTAL    PATHOLOGY   AND    PRACTICE. 


A.  Osteoma  on  the  body  of  the  root  (Fig.  65,  a,  b). 

B.  Osteoma  on  the  apex  of  the  root  (Fig.  66,  a,  b). 

Either  of  these  appears  mostly  upon  teeth  the  crowns  of  which 
are  more  or  less  destroyed  by  caries,  with  probably  a  long-standing 
exposed  pulp,  which  seems  to  plainly  indicate  that  their  cause  is  likely 
to  be  accounted  for  in  localized  pericementitis  from  this  source.  If, 
however,  we  bear  in  mind  that  the  destruction  of  the  life  of  the  pulp 
prevents  or  stops  the  formation  of  osteoma  on  the  roots,  we  must 
come  to  the  conclusion  that  such  tumors  had  commenced  their 
formation  long  before  the  exposure  of  the  pulp,  or  that  the  pulp  must 
have  remained  alive  for  a  very  long  time  after  its  exposure  before  it 
died,  causing  during  this  long  time  a  slight  but  constant  irritation  of 
this  tissue,  which  was  transferred  to  the  pericementum. 


Fig.  65. 


Fig.  66. 


As  soon  as  severe  pericementitis  sets  in  from  an  exposed  pulp, 
unless  vigorous  steps  are  taken  for  its  relief,  the  pulp  is  in  a  fair  way 
to  become  lifeless  very  soon.  After  its  death  severe  pericementitis 
and  its  distressing  terminations  are  too  well  known  to  practitioners  to 
need  mentioning  here.  In  neither  of  the  latter  instances  would  we 
expect  a  bony  outgrowth  on  the  roots.  It  is  only  an  irritation  of 
the  pericementum  while  the  pulp  is  living  that,  in  my  judgment,  can 
result  in  an  increased  cementum. 

In  some  persons,  or  conditions  of  persons,  a  very  superficial  decay, 
more  particularly  upon  the  necks  of  teeth,  will  produce  marked  peri- 
cementitis and  neuralgia.  We  may  infer  from  this  fact  that  in 
other  persons  or  conditions  (or  possibly  the  same),  perhaps  under 
the  influence  of  constitutional  disturbances,  a  local  irritation  of  the 
pericementum  is  induced,  causing  exostosis,  long  before  exposure  of 
the  pulp  had  occurred. 


II. — Diffused  Hyperostosis  with  Roots  Separated. 

(Fig.  67,  a,  b,  c.) 

Under  this  heading  a  large  number  of  specimens  of  my  collection 
can  be  included,  both  of  otherwise  sound  teeth  and  those  decayed 


HYPEROSTOSIS    OF    ROOTS    OF   TEETH. 


175 


or  filled.  As  I  have  said  before,  I  will  admit  that  pericementitis  from 
caries  is  a  cause  of  hyperostosis  only  when  one  root  or  two  be  in- 
volved, and  others  in  a  normal  condition,  the  enlarged  root  or 
roots  corresponding  to  the  carious  cavity  either  on  the  neck  or 
crown  of  the  tooth.  When  all  the  roots  of  molars  are  affected, 
without  the  least  symptom  of  disease  upon  the  exposed  portion  of 
the  tooth  in  the  mouth,  I  can  see  no  other  correct  course  but  to  seek 
for  the  cause  of  the  malformation  in  the  beginning  of  the  formation 
■of  the  cementum,  to  wit,  during  the  first  year  of  extra-uterine  life. 
Hyperostosis  of  this  kind  invades  the  roots  from  the  apex  to  the 
middle,  to  two-thirds  their  length,  sometimes  even  to  their  necks. 
The  enlargement  either  blends  with  the  crown,  without  a  distinct 
boundary  line,  or  there  is  a  more  or  less  marked  bulging  of  the 
augmented  tissue.  The  enlarged  portion  is  either  in  a  more  or  less 
horizontal  line  or  is  fluted,  with  here  and  there  irregular  prolonga- 


FiG.  68. 


tions  toward  the  crown.  In  one  instance  I  have  seen  a  small 
enamel-nodule  corresponding  exactly  to  the  summit  of  a  marked 
conical  prolongation  of  the  cementum.  Sometimes  the  bulging  of 
the  cementum  reaches  the  crown,  and  may  be  distinctly  seen  over- 
lapping the  enamel.  Such  formations  are  usually  either  smooth  or 
slightly  nodulated.  Sometimes  they  are  corroded  as  if  by  inflamma- 
tion ;  and,  again,  upon  a  comparatively  smooth  mass  there  may  be 
found  bulging  forth  an  irregular  nodule  of  circumscribed  osteoma, 
evidently  the  result  of  an  excessive  formative  pericementitis. 

In  one  of  my  specimens,  a  left  upper  second  molar,  there  is  upon 
the  anterior  surface  of  the  buccal  root  a  pit  two  and  a  half  millime- 
ters in  diameter  and  one  [millimeter  in  depth,  the  base  of  the  pit 
being  finely  corroded  and  nodular.  On  the  same  surface  numerous 
small  nodules  are  scattered  about.  On  the  neck  the  hyperplastic 
cementum  is  one  millimeter  in  thickness,  and  terminates  all  around 
it  in  a  nearly  abrupt  line.     (Fig.  68,  a.) 

On  a  right  upper  second  molar  the  palatal  root  exhibits  at  its 
apex  a  cauliflower-like  excrescence,  upon  a  comparatively  smooth 
osteoma,  about  one   millimeter   in   thickness,  occupying  the  upper 


176  DENTAL   PATHOLOGY   AND    PRACTICE. 

two-thirds  of  the  root.  The  excrescence  sends  a  delicate  conical 
offshoot  to  the  mass  which  cements  the  buccal  roots  together.  The 
posterior  portion  of  the  crown  of  this  tooth  has  a  carious  cavity  in  it 
the  size  of  a  French  pea,  with  the  pulp-chamber  opened.  (Fig.  68,  b.) 
Roots  of  this  kind  look  very  clumsy  and  shortened,  for  the  reason 
that  at  the  place  of  their  union  the  hyperostosis  forms  a  heavier  mass, 
which  has  more  or  less  filled  the  space  between  them  ;  still  they 
remain  separate  to  a  considerable  extent. 

III. — Diffused  Hyperostosis  with  Roots  United. 

This  group  may  be  subdivided  as  follows  : 

A.  Apices  free  and  straight. 

B.  Apices  free  and  curved. 

C.  All  roots  united  their  entire  length. 

Teeth  of  group  A  are  characterized  by  an  osseous  outgrowth  of 
cementum  accumulating  at  the  point  of  junction  of  the- roots, — the 
roots  themselves  being  either  slender  and  free  from  osteoma  or 
slightly  thickened.  An  upper  third  molar  presenting  this  anomaly 
has  five  roots,  three  of  which  are  normal  at  their  apices,  the  fourth 
being  the  seat  of  a  diffused  hyperostosis  encircling  it,  and  the  fifth  root 
being  rudimentary.  All,  however,  are  united  into  a  common  mass 
a  short  distance  from  their  apices,  which  mass  gradually  blends  with 
the  enamel.     (Fig.  69,  a.) 

Fig.  69. 


Teeth  of  group  B  exhibit  a  union  of  the  roots  with  markedly 
devious  but  slender  apices.  A  left  upper  second  molar  of  my  collec- 
tion shows  this  evidently  rare  anomaly.  The  palatal  root  is  slightly 
devious,  with  an  apex  arising  from  the  main  mass  of  the  root  at  a 
right  angle.  The  buccal  root  (there  is  but  one)  shows  two  curva- 
tures, both  at  right  angles.  The  osteoma  is  only  moderately  large, 
and  on  the  posterior  surface,  at  the  point  of  junction  of  the  roots, 
there  is  wedged  in  a  sessile  oblong  nodule,  below  which  is  a  shallow 
furrow,  indicating  the  original  point  of  separation  of  the  two  roots. 
The  crown  of  this  tooth  is  not  decayed.     (Fig.  69,  b.) 

Teeth  of  group  C  are  rather  common.  In  third  molars  or  wisdom- 
teeth,  both  of  the  upper  and  lower  jaws,  a  union  of  the  roots  is  quite 


HYPEROSTOSIS   OF    ROOTS   OF   TEETH.  177 

generally  their  normal  condition.  Osteoma,  when  found  upon  such 
roots,  is  either  a  clumsy  nodular  mass  without  any  sign  of  a  pre- 
vious separation,  or  slight  furrows  may  be  visible  indicative  of  such 
separation  of  the  roots.     (Fig.  69,  c.) 

There  is  a  history  connected  with  a  lower  left  third  molar  in  my 
collection  that  I  will  give  in  abstract,  feeling  that  it  may  be  of  inter- 
est to  some.  It  exhibits  a  diffused  osteoma,  ridged  and  nodulated, 
with  a  bent  apex  toward  the  ramus.  It  was  extracted  from  the  mouth 
of  a  lady  some  -years  since  by  my  friend.  Dr.  S.  A.  Main,  of  this 
city,  who  kindly  presented  it  to  me  with  the  following  history  :  For 
some  ten  years  this  lady  had  suffered  most  excruciatingly  from  facial 
neuralgia.  She  consulted  the  best  medical  talent  at  home  without 
obtaining  the  slightest  relief  Finally,  some  three  years  before  the 
tooth  was  removed,  she  went  to  London,  where  it  was  determined 
by  the  surgeon  who  was  called  to  attend  her  that,  in  order  to  afford 
any  relief,  it  would  be  necessary  to  sever  the  facial  nerve  upon  the 
side  which  seemed  the  most  affected,  which  was  done, — with,  how- 
ever, only  temporary  relief  With  the  hope  that  the  slight  cessation 
of  pain  would  be  speedily  followed  by  permanent  cure,  she  went 
to  Paris,  anticipating  the  pleasure  of  a  comfortable  tour  of  the 
Continent,  but  in  a  few  days  the  pain  again  returned  with  renewed 
energy.  She  then  consulted  a  surgeon,  who  decided  that  the  only 
chance  for  permanent  relief  was  to  have  the  facial  nerve  divided 
upon  the  other  side  of  the  face.  The  operation  was  done  with  no 
better  results  than  from  the  first.  Finally  she  concluded  to  return 
to  her  home  in  New  York,  there  to  spend  the  few  days  (as  she 
supposed)  which  she  had  to  live  as  comfortably  as  possible.  Shortly 
after  arriving  at  her  home  she  consulted  her  dentist  (whom,  by 
the  way,  she  had  never  thought  to  consult  before  in  reference  to  her 
neuralgia),  and  as.ked  him  to  look  at  this  tooth,  saying  at  the  same 
time  that  it  often  felt  quite  sore  to  the  touch.  (Its  antagonist  had 
been  taken  out  many  years  before.)  After  examination,  she  was  ad- 
vised to  have  it  taken  out,  which  was  done.  Immediately  upon  its 
removal  the  lady  realized  that  the  cause  of  her  long-continued,  fear- 
fully distressing,  and  very  expensive  neuralgia  had  been  found  at 
last,  which  proved  to  be  true.  She  then  told  Dr.  Main  that  that 
tooth  had  cost  her  ten  thousand  dollars. 

IV. — Union  of  Two  Teeth  through  Hyperostosis. 

Of  this  rare  occurrence  of  the  osseous  union  of  teeth  I  have  eight 
or  ten  fine  specimens.     The  subdivision  suggesting  itself  is  as  follows  : 

A.  Union  of  the  roots  at  their  apices  (Fig.  70,  a,  b). 

B.  Union  of  the  roots  at  their  middle  (Fig.  71,  a,  b). 

C.  Complete  union  of  the  roots  (Fig.  71,  c). 

13 


178 


DENTAL   PATHOLOGY   AND    PRACTICE. 


The  first  group  is  characterized  by  a  union  of  devious  roots  of 
neighboring  teeth.  As  both  of  my  specimens  show  a  partial  carious 
destruction  of  their  crowns,  the  idea  may  suggest  itself  that,  owing 
to  a  destruction  of  the  intervening  alveolar  wall,  and  owing  to  gravi- 
tation, the  roots  became  attached  to  each  other  through  an  inflamma- 
tory process.  At  the  same  time  serious  objections  may  be  raised 
against  such  a  view.  The  main  objection  is  that  an  inflammation  of 
the  pericementum  sufliciently  intense  to  destroy  the  alveolus  would 
be  very  liable  to  destroy  the  pericementum  itself,  to  such  a  degree  as 
to  render  the  secondary  new  formation  of  cementum  necessary  for 
agglutination  of  the  neighboring  roots  quite  impossible.  Should  we 
assume  that  the  septum  was  originally  absent,  the  only  way  of 
explaining  such  formations  is  to  assume  that  at  least  one  of  the  germs 
of  the  coalesced  teeth  was  malposed  at  the  time  of  the  embryonic 
arrangement.  In  this  view,  it  will  be  observed,  the  alveolar  septum 
did  not  form  at  all,  and  at  the  time  of  development  of  the  roots  the 
mutual  pressure  was  sufficient  to  cause  irritation  leading  to  a  new 
formation.  I  conclude,  therefore,  that  the  carious  destruction  of  the 
crowns  was  merely  a  coincidence  rather  than  a  cause.  (Fig.  70,  a.) 
The  roots  of  one  tooth  are  mere  stumps  left  after  carious  destruction 
of  the  crown  and  a  portion  of  the  roots.  Here  the  hyperplastic 
cementum  of  the  stumps  is  jagged  and  nodular,  plainly  indicating 
that  the  already  formed  outgrowth  of  cementum  has  been  destroyed 
by  cementitis  in  a  secondary  manner.     (Fig.  70,  d.) 


Fig.  70. 


Fig.  71. 


Group  B  shows  a  concretion  of  neighboring  roots  of  molars  at  the 
middle  upon  one  side,  and  at  the  apices  upon  the  other.  (Fig.  71,  a.) 
One  of  the  crowns  is  slightly  affected  by  caries, — by  no  means,  how- 
ever, to  such  a  degree  as  to  account  for  agglutination  of  the  two  teeth, 
the  enlarged  cementum  of  which  is  mainly  smooth.  Fig.  Ji,  6,  rep- 
resents two  molars  grown  together  nearly  the  entire  length  of  their 
roots  ;  both  teeth  being  otherwise  sound.  One  of  them  shows  at 
its  neck  an  "  enamel-drop,"  which  feature  I  consider  a  further  proof 
of  the  embryonal  malformation  of  such  teeth.     Some  exostoses  from 


HYPEROSTOSIS    OF    ROOTS    OF    TEETH. 


179 


the  sockets  are  attached  to  the  roots,  which  in  my  judgment  proves 
merely  a  secondary  hyperplastic  pericementitis. 

Group  C  is  represented  by,  but  one  specimen, — an  upper  cuspid 
united  with  a  neighboring  lateral  incisor.  This  seems  to  be  a 
case  which  may  be  considered  an  exception  to  the  rule, — viz,  that 
only  bicuspids  and  molars  are  thus  affected.  In  this  case  the  union 
is  perfect  the  entire  length  of  the  roots,  and  only  shallow  furrows  on 
the  outer  and  inner  surfaces,  reaching  nearly  to  a  common  apex,  in- 
dicate the  previous  separation.  The  apex  presents  but  one  large 
common  foramen.  At  the  necks  of  both  teeth  there  is  shallow  ca- 
rious destruction, — not,  however,  exposing  the  pulp-chambers.  All 
these  features  furnish  us  proof  of  a  fetal  malformation. 

Fig.  72 


Longitudinal  Section  of   Hyperplastic   Cementum  slightly  bulging  toward   the 
Neck  of  the  Tooth  (Upper  Bicuspid). 

D,  dentine ;  N,  neck  ;  P,  pericementum  ;  O,  globular  or  osteo-dentine  ;  G,  granular  layer ; 
H,  hyperplastic  cementum  irregularly  lamellated,  with  irregularly  distributed  cement-cor- 
puscles; il/,  medullary  canal.    Magnified  150  diameters. 

For  the  purpose  of  examining  this  disease  microscopically,  I  have 
ground  quite  a  large  number  of  specimens  from  teeth  which  were 
placed  in  dilute  alcohol  immediately  after  their  extraction,  in 
order  to  keep  them  constantly  wet,  and  to  preserve  their  soft  parts. 
During  the  process  of  grinding  they  were  also  kept  under  water. 
All  the  specimens  showed  a  number  of  features  in  common  which  are 
represented  with  a  comparatively  low  power  in  Fig.  72.  Those 
which  I  wish  to  call  attention  to  are  as  follows  : 

The  dentine  in  some  specimens,  perhaps  in  several  localities  in  the 


l8o  DENTAL    PATHOLOGY   AND    PRACTICE. 

same  specimen,  was  found  in  a  normal  condition  ;  and  in  others  it 
exhibited  the  so-called  interglobular  spaces,  varying  greatly  in  size 
and  number,  indicative  of  an  incomplete  calcification. 

In  some  specimens  the  dentinal  canaliculi  of  the  roots  were  arranged 
in  bundles,  between  which  were  found  areas  scantily  provided  with  or 
altogether  destitute  of  canaliculi.  In  these  areas,  are  often  seen  small 
interglobular  spaces,  sometimes  in  direct  union  with  a  few  canaliculi. 

The  interzonal  layer  between  dentine  and  cementum  invariably 
exhibited  formations  known  under  the  name  of  osteo-dentine,  or 
globular  dentine,  either  as  the  result  of  "  eburnitis"  or  of  incomplete 
calcification.  It  is  a  condition  kindred  to  the  interglobular  spaces 
of  Czermak.  Such  formations,  as  a  rule,  extend  into  the  neck  of  a 
tooth, — where,  however,  they  are  more  scanty  than  on  the  roots.  A 
striking  feature  is  their  entire  absence  at  the  point  of  junction  of  the 
roots.  Here  the  cementum  is  found  in  contact  with  an  irregular 
formation  of  dentine  (vaso-dentine),  which  will  be  described  farther 
on.  Wedl  seems  to  have  been  the  first  to  illustrate  this  formation, — 
without,  however,  making  an  allusion  to  it  in  his  text. 

Next  to  the  layer  of  osteo-dentine  a  layer  is  invariably  found 
which,  under  lower  powers  of  the  microscope,  looks  coarsely  granu- 
lar, and  which  in  consequence  I  propose  to  call  the  granular  layer. 
It  is  destitute  of  cement- corpuscles,  and  as  a  rule  is  the  only  layer 
of  cementum  of  the  neck  of  the  tooth,  whenever  this  gradually 
slopes  from  the  hyperplastic  cementum  to  the  enamel.  Next  follows 
the  enlarged  cementum  itself,  usually  characterized  by  a  large  num- 
ber of  irregular  lamellae  more  or  less  concentric  to  the  axis  of  the 
root.  Some  areas  may  be  found  destitute  of  lamellae  ;  others  very 
abundantly  supplied  "wdth  them.  At  the  border  of  the  cementum 
toward  the  crown,  where  the  former  is  often  found  bulging  to  a  consid- 
erable extent,  the  lamellae  are  found  parallel  with  the  outer  periphery 
of  the  cementum,  inosculating  with  the  granular  layer  at  obtuse  angles. 

In  the  lamellated  basis-substance  are  found  scattered  cement-cor- 
puscles. The  most  striking  features  of  these  corpuscles  are  as  follows  : 
First,  they  are  far  more  irregularly  distributed  in  the  basis-sub- 
stance than  in  normal  cementum.  In  some  portions  of  the  hyper- 
plastic cementum  such  corpuscles  are  comparatively  few,  whether 
the  lamellae  be  plainly  marked  or  not ;  in  other  portions  they  are 
arranged  in  groups  or  clusters  without  apparently  any  regularity. 
Second,  the  cement-corpuscles,  as  a  rule,  are  smallest  near  the  gran- 
ular layer,  and  largest  toward  the  periphery  ;  at  the  latter  portion 
their  offshoots  are  much  wider  and  more  irregular,  often  piercing  the" 
lamellae  at  right  angles.  No  constant  relation  between  lamellae  and 
cement- corpuscles  is  to  be  found.  Third,  the  cement-corpuscles  are 
to  be  seen  occasionally  in  large  numbers  clustered  together  in  longi- 


HYPEROSTOSIS    OF    ROOTS    OF    TEETH. 


I8l 


tudinal  groups.  This  is  probably  caused  by  the  previous  presence 
of  medullary  canals,  the  tissue  of  which,  at  a  comparatively  late 
period,  has  given  rise  to  a  large  number  of  cement-corpuscles,  with  a 
comparatively  small  quantity  of  basis-substance  between  them. 

The  hyperplastic  cementum  is  often  traversed  by  medullary  canals 
carrying  central  blood-vessels.  These  are  most  numerous  at  or  near 
the  point  of  junction  of  the  roots,  where,  as  first  described  by  Tomes, 
even  normal  cementum  may  sometimes  contain  medullary  canals. 
The  vessels  of  these  medullary  canals,  also  first  described  by  Tomes, 
with  whom  I  am  pleased  to  agree,  are  in  direct  connection  and  an- 
astomose with  the  blood-vessels  of  the  pericementum.  In  one  of 
my  specimens  the  cementum  of  the  neck  exhibits  peculiar  features. 

Fig.  73- 


S  v.:  ••■--';  AT- 


Hyperplastic  Cementum  of  the  Neck  of  a  Molar.    Longitudinal  Section. 
N,  zone  of  coarsely-granulated  cementum,  traversed  by  bundles  of  coarse  canaliculi  ;   G, 
granular  zone,  destitute  of  canaliculi ;   O,  zone  of  globular  dentine ;  D,  dentine  with  canaliculi 
stopping  short  of  the  cementum.     Magnified  500  diameters. 

Instead  of  the  coarsely-granular  layer  usually  present,  and  previously 
alluded  to,  there  is  a  zone  traversed  at  nearly  right  angles  by  bun- 
dles of  canaliculi,  very  broad  and  having  no  connection  whatever  with 
cement-corpuscles.  Above  this  zone  is  the  ordinary  granular  zone, 
bordered  toward  the  dentine  by  a  thin  layer  of  globular  dentine  ; 
next  is  the  finely-granular  layer  of  the  dentine  itself,  with  very  few 
or  no  canaliculi,  and  at  last  we  come  to  the  canaliculated  dentine  of 
normal  development.     (Fig.  73.) 


l82 


DENTAL   PATHOLOGY   AND    PRACTICE. 


High  amplifications  plainly  reveal  the  structure  of  the  interzonal 
layer  between  dentine  and  hyperplastic  cementum.  The  dentine 
often  shows  interglobular  spaces,  which  as  a  rule  are  filled  with 
granular  protoplasm,  and  serve  as  the  termination  of  some  dentinal 

Fig.  74. 


Interzonal  Layer  between  Dentine  and  Hyperplastic  Cementum  of  a  Molar. 

Longitudinal  Section. 
D,  dentine  with  small  interglobular  spaces  ;  O,  osteo-dentine,  above  which,  in  the  granular 
layer  G,  there  is  a  large  irregular  interglobular  space  ;  C,  C,  cement-corpuscles  with  long  par- 
allel ofishoots.     Magnified  600  diameters. 

canaliculi ;  especially  for  their  tenants,  their  fibers  of  living  matter. 
The  interglobular  spaces  nearest  to  the  cementum  sometimes  inoscu- 
late directly  with  the  interstices  between  the  globular  masses  of  calci- 
fied basis-substance,  constituting  the  tissue  termed  osteo-dentine  or 
globular  dentine.  The  globules  themselves  vary  greatly  in  size. 
They  usually,  however,  correspond  with  the  bulk  of  one  or  of  a  lim- 


HYPEROSTOSIS    OF    ROOTS   OF   TEETH.  183 

ited  number  of  medullary  corpuscles  present  before  their  transforma- 
tion into  basis-substance.  The  interstices  between  the  globules  also 
vary  in  size,  and  send  offshoots  into  the  larger  globules,  subdividing 
them  into  incomplete  smaller  ones.  All  of  them  contain  granular 
protoplasm.  In  the  granular  zone  next  to  the  layer  of  osteo-den- 
tine  we  sometimes  meet  with  very  large  and  irregular  interglobular 
spaces,  apparently  having  no  direct  connection  with  the  offshoots  of 
cement- corpuscles.  In  several  specimens  I  have  seen  arising  from  the 
cement- corpuscles  very  long  and  slightly  wavy  offshoots,  which, 
owing  to  their  parallel  course,  bear  a  close  resemblance  to  dentinal 
canaliculi.  Formations  of  this  kind  occur  only  In  those  layers  of 
hyperplastic  cementum  nearest  to  the  dentine,  and  always  lose  them- 
selves in  the  granular  layer  above  the  osteo-dentine  without  directly 
communicatmg  with  the  dentinal  canaliculi  proper.  (Fig.  74.)  The 
medullary  canals  traversing  the  enlarged  cementum  either  contain  me- 
dullary corpuscles  and  capillary  blood-vessels,  or  they  are  filled  with 
highly-refracting  granules  and  globules  of  lime-salts,  as  described 
by  Wedl.  Should  their  canals  become  obliterated,  they  give  rise  to 
groups  of  cement-corpuscles  within  a  scantily  calcified  basis-substance. 
At  the  point  of  junction  of  the  enlarged  roots  I  have  met  with 
a  peculiar  formation  of  dentine  in  several  of  my  specimens,  which, 
owing  to  the  presence  of  a  large  number  of  vascular  canals,  I  propose 
to  term  vaso-dentine.  To  the  naked  eye,  in  the  prepared  speci- 
men, is  presented  a  high  degree  of  transparency,  which  at  once  dis- 
tinguishes it  from  the  neighboring  opaque  portions  of  normal  den- 
tine and  from  cementum.  Low  powers  of  the  microscope  reveal  in 
this  dentine  a  varying  number  of  medullary  canals,  in  either  a  par- 
allel or  plexiform  arrangement.  The  canaliculi  contain  medullary 
tissue  and  capillary  blood-vessels,  one  or  two  in  each  canal.  Some- 
times glistening  granules  of  lime-salts  are  found,  more  especially  in 
dilated  portions  of  the  canals.  Offshoots  of  such  canals  may  inoscu- 
late with  very  narrow  canals  containing  granular  protoplasm  only. 
The  surrounding  basis-substance  is  scantily  supplied  with  extremely 
fine  canaliculi,  running,  without  any  apparent  regularity,  either  in  fan- 
shaped  groups  or  parallel  with  the  medullary  canals,  or  in  the  shape 
of  a  fountain,  encircling  the  canals  with  the  most  beautiful  and  striking 
figures.  Some  portions  of  the  basis-substance  may  look  granular 
and  devoid  of  canaliculi  ;  others  (and  these  form  a  vast  majority) 
are  apparently  homogeneous,  and  scantily  supplied  with  extremely 
minute  canaliculi.  The  cementum  is  directly  on  the  border  of  the 
vaso-dentine,  without  any  intervening  layer  of  granular  dentine,  and 
the  cement-corpuscles  nearest  to  the  dentine  are  in  direct  connection 
with  the  dentinal  canaliculi  themselves.  (Fig.  75.)  Higher  powers 
of   the  microscope  brought  to  bear  upon  the  vaso-dentine  plainly 


DENTAL    PATHOLOGY   AND    PRACTICE. 


show  the  medullary  contents  of  the  medullary  canals,  in  which  may 
also  be  seen  one  or  two  capillary  blood-vessels.  Both  the  canals  and 
blood-vessels  produce  loops,  as  indicated  by  their  abrupt  termina- 
tions in  vertical  sections,  and  are  unquestionably  in  communication 
with  the  blood-vessels  of  the  pericementum  (Tomes).  A  peculiar 
feature  of  the  vaso-dentine  is  that  portions  freely  supplied  with  vas- 
cular canals  contain  a  considerably  larger  number  of  dentinal  cana- 
liculi  than  those  devoid  of  vascular  canals. 

Fig.  75. 


LV-D 


Vaso-Dentine  from  the  Junction  of  the  Enlarged  Roots  of  an  Upper  Molar. 
Longitudinal  Section. 

Z>,  primary  dentine;  F'-Z',  vaso-dentine  traversed  by  medullary  canals  in  a  plexiform  ar- 
rangement. The  canals  contain  either  blood-vessels  or  glistening  depositions  of  lime-salts. 
B,  basis-substance  of  dentine  scantily  provided  with  extremely  delicate  canaliculi ;  in 
some  places  fan-  and  fountain-shaped  figures  of  dentinal  canaliculi  are  discernible ;  C,  hy- 
perplastic cementum,  lamellated,  and  containing  a  medullary  canal.    Magnified  50  diameters. 

The  canaliculi  in  the  neighborhood  of  the  vascular  canals  are  very 
irregular  in  their  course,  as  before  stated,  and  often  loop-shaped, 
starting  from  and  inosculating  with  the  same  vascular  canal.  Again, 
we  find  them  starting  from  club,  pear,  spindle,  and  irregular-shaped 
spaces,  containing  medullary  corpuscles,  or  granular  protoplasm,  but 
no  blood-vessels  (Fig.  76).  As  an  additional  feature  of  hyperostosis 
of  the  roots,  I  would  mention  that  in  all  my  specimens  the  pulp- 
chamber  and  often  the  canals  appear  considerably  narrowed  by 
heavy  formations  of  secondary  dentine.  Besides,  the  pulp-tissue 
was  found  to  contain  the  formations  of  secondary  dentine  known  as 
pulp-stones,  or  was  crowded  with  globular  calcareous  depositions  hav- 
ing no  distinct  structure.     In  the  majority  of  the  teeth  the  enamel  also 


HYPEROSTOSIS    OF    ROOTS    OF   TEETH. 


185 


was  imperfectly  formed,  generally  presenting  a  highly  pigmented  and 

imperfectly- calcified  appearance,  with  the  enamel-rods  very  irregular 

and  curly. 

Fig.  76. 


m_v-D 


^B-JD 


Vaso-Dentine  from  the  Point  of  Junction  of  the  Enlarged  Root  of  an  Upper 
Bicuspid.    Longitudinal  Section. 

V-Z>,  a  portion  of  vaso-deiitine  with  three  parallel  vascular  canals,  and  very  irregular,  often 
looped,  canaliculi,  some  starting  from  the  vascular  canals  and  others  from  smaller  medullary 
spaces.  B-D,  dentine  of  great  transparency,  with  scanty  canaliculi.  The  boundary  line  be- 
tween the  two  portions  is  abrupt,  with  numerous  bay-like  excavations.  Magnified  500  diame- 
ters. 

A  Striking  feature  in  all  microscopical  specimens  of  hyperplastic 
cementum  is  the  great  number  and  large  size  of  the  offshoots  of  the 
cement-corpuscles,  the  formerly  so-called  canaliculi.  The  reason 
for  this  seems  to  be  that   both  the  corpuscles  (lacunae)  and   their 


i86 


-DENTAL   PATHOLOGY   AND    PRACTICE, 


coarser  ofifshoots  (canaliculi)  are  filled  with  air,  or  with  dirt  from  the 
grinding,  which  causes  them  to  look  black.  If,  however,  we  place  a 
carefully  but  not  completely  decalcified  portion  of  this  tissue,  mounted 
in  glycerin,  under  a  very  high  power,  we  are  struck  with  its  beautiful 
and  graceful  appearance.  It  is  identical  in  structure  with  normal 
cementum.  The  basis-substance  forms  cavities  which  contain  nu- 
cleated protoplasmic  bodies,  the  cement-corpuscles  proper,  having  a 
markedly  reticulated  structure. 

Between  the  periphery  of  the  cement-corpuscles  and  that  of  the 
lacunae  there  is  a  narrow  light  rim,  obviously  corresponding  to  a  space 
which  serves  for  the  circulation  of  the  nutritive  fluids.  The  lacunae  at 
its  periphery  are  interrupted  by  numerous  offshoots,  more  irregular 

Fig.  77. 


Hyperplastic  Cementum  of  an  Upper  Molar.    Cross  Section. 
Magnified  1500  diameters. 

and  wider  than  those  of  normal  cementum.  These  canaliculi  form 
an  extremely  delicate  reticulum  throughout  the  basis-substance, 
interconnecting  the  neighboring  lacunae  (indeed,  all  lacunae)  of  the 
cementum. 

Starting  from  the  periphery  of  the  cement-corpuscles,  conical  ofif- 
shoots run  into  the  canaliculi ;  the  broader,  of  course,  the  wider  the 
canaliculus.  The  coarsest  ofifshoots  still  exhibit  a  reticular  structure  ; 
whereas  the  finest  are  merely  beaded  threads  occupying  the  middle  of 
the  canaliculi.  Thus  it  will  be  seen  that  all  canaliculi  hold  filaments 
of  living  matter  in  a  cobweb-like  arrangement,  and  thus  it  becomes 
plain  that  hyperplastic  as  well  as  normal  cementum  is  a  living  tissue 
throughout.     The  reticular  structure  of  the   living   matter   in    the 


CONDITIONS   UNFAVORABLE   TO    DENTAL    OPERATIONS.         1 87 

corpuscle  itself  is  plainly  visible.  The  inert  basis-substance,  which 
is  infiltrated  with  lime-salts,  is  located  in  the  meshes  of  the  reticulum 
of  the  canaliculi,  and  between  the  basis-substance  and  filaments  of 
living  matter  a  slow  circulation  is  going  on,  the  liquid  carrying 
nourishment  and  taking  away  the  effete  material.  (Fig.  77.) 
Thus  it  is  that  pathological  changes  of  a  pathological  tissue  become 
intelligible,  and  cementitis  of  hyperplastic  cementum,  as  described 
and  illustrated  by  Wedl,  under  the  term  "perforating  resorption,"  is 
understood. 

I  have  already  described  this  condition  macroscopically.  Under 
the  microscope  it  is  characterized  by  the  presence  of  cavities  filled 
with  medullary  corpuscles,  or  multinuclear  protoplasmic  masses,  and 
bounded  toward  the  unchanged  cementum  with  numerous  bay-like 
excavations.  The  destruction  may  involve  superficial  portions  of 
the  tumor  only,  or  the  entire  mass  down  to  the  dentine.  As  there 
is  little  tendency  to  suppurative  pericementitis,  the  termination  of 
the  inflammatory  process  undoubtedly  results  often  in  a  re- formation 
of  cementum,  the  same  as  takes  place  during  the  process  of  absorp- 
tion of  the  roots  of  temporary  teeth.  Under  these  circumstances 
the  bay-like  excavations  are  refilled  with  bone-tissue,  and  the  bays 
are  recognizable  by  sharply-defined  lines  corresponding  to  the  ter- 
ritories of  the  cement-corpuscles.  Some  of  my  specimens  exhibit 
bay-like  excavations  separating  the  cementum  from  the  dentine,  and 
the  bays  filled  with  bone-tissue  crowded  with  cement-corpuscles. 
In  other  specimens  certain  portions  of  the  hyperplastic  cementum 
show  distinct  circular,  semicircular,  or  crescentic  lines  corresponding 
to  the  territory  of  one  or  more  cement-corpuscles. 


CHAPTER   XIX. 


CONDITIONS  OF  PATIENTS  DURING  WHICH  SEVERE  DENTAL  OPERA- 
TIONS SHOULD  BE  AVOIDED. 

It  is  a  well-understood  fact  among  general  practitioners,  surgeons 
particularly,  that  in  some  conditions  of  the  system  the  periosteum  is 
more  susceptible  to  slight  irritation  than  in  others.  These  conditions 
are  anemia,  as  found  in  scrofula,  and  general  debility  from  overwork, 
either  mental  or  physical  ;  during  gestation  and  lactation,  and  during 
active  constitutional  syphilis. 

All  such  cases  appeal  to  the  gentlest  care  of  the  practitioner  of 
dental  surgery,  as  he  can  do  very  little  without,  in  a  measure,  disturb- 
ing this  delicate  covering  of  the  bones  (alveoli)  and  of  the  roots  of 
the  teeth. 


1 88  DENTAL    PATHOLOGY   AND    PRACTICE. 

The  filling  of  teeth  with  gold  for  patients  during  the  existence  of 
any  of  the  above  debilitated  and  debilitating  conditions  should  be 
carefully  avoided  ;  teeth  should  never  be  extracted  if  it  is  possible 
to  keep  them  comfortably  in  the  mouth.  In  short,  no  operation  that 
will  produce  severe  irritation  of  this  membrane  should  be  undertaken 
while  such  condition  continues. 

During  gestation  there  is  generally  a  greater  tendency  to  caries  of 
the  teeth  than  at  any  other  period  of  adult  life.  This  is  probably 
due  to  the  fact  that  slight  irritation  of  the  system  is  usually  present, 
which  causes  more  rapid  fermentation  of  particles  of  food  around  and 
between  the  teeth  than  is  usually  the  case,  consequently  a  more 
acid  condition  of  the  fluids  of  the  mouth.  It  has  been  suggested 
that  for  the  building  up  of  the  osseous  structure  of  the  fetus  during 
gestation  lime-salts  are  withdrawn  from  the  bones  and  teeth  of  the 
mother,  thus  rendering  the  teeth  more  frail,  and  liable  to  more  rapid 
destruction  by  caries.  This,  I  am  convinced,  is,  generally  speaking,  a 
false  theory.  The  teeth,  however,  like  all  other  organs  of  the  human 
body,  require  nourishment  ;  and  if,  during  this  period,  the  mother 
suffers  from  daily  and  almost  constant  nausea,  so  much  so  that  suffi- 
cient nourishment  cannot  be  retained  for  herself  and  the  building  up 
of  the  fetus,  then  it  may  be  possible  that  the  deficiency  in  osseous 
material  is  drawn  from  that  of  the  mother.  Under  such  circum- 
stances the  ' '  morning  sickness' '  may  be,  and  is,  controlled  in  a  great 
measure  by  the  use  of  ingluvin  given  in  ten  to  twenty  grain  doses 
three  or  four  times  a  day  ;  the  following  also  are  said  to  be  effica- 
cious in  relieving  this  distressing  condition  : 

R  — Oxylate  of  cerium,  gr.  j  ; 
Subnitrate  of  bismuth,  gr.  v. 
Sig  — Three  times  a  day. 

R — Fl.  ex.  valerian,  ^j  ; 

Fowler's  sol.  arsenic,  ""Kxvj  ; 
Bicarbonate  of  soda,  5J. 
Sig. — A  teaspoonful  every  two  or  three  hours. 

Should  these  fail  to  relieve  the  patient,  then  syrup  of  lacto- 
phosphate  of  lime  should  be  given,  in  tablespoonful  doses,  in  half  a 
glass  of  water,  three  times  a  day,  half  an  hour  before  eating,  every 
alternate  week,  to  not  only  provide  the  necessary  amount  of  lime- 
salts  for  the  proper  sustenance  of  the  equilibrium  of  the  mother's 
osseous  structure,  but  to  furnish  that  which  the  fetus  may  need  ;  but 
in  cases  where  the  usual  nourishment  is  taken  and  retained  by  the 
mother,  the  phosphate  of  lime  is  not  indicated. 

During  lactation  also  the  drain  upon  the  mother  is  often  very  severe, 
reducing  the  system  to  a  condition  of  anemia  quite  sufficient  to  permit 


CONDITIONS    UNFAVORABLE    TO    DENTAL    OPERATIONS.         1 89 

it  to  be  seriously  affected  by  any  undue  local  injury.  Consequently, 
in  teeth  requiring  filling  either  cement  or  gutta-percha  should  be  used 
until  a  more  robust  conciition  of  health  has  been  secured. 

Duringthecontinuanceof  these  two  conditions  (gestation  and  lacta- 
tion) the  teeth  of  mothers,  as  before  stated,  are  subject  to  excessive 
caries,  and  are  generally  extremely  sensitive  ;  so  much  so  that  severe 
neuralgia  often  supervenes.  To  relieve  this,  a  solution  of  bicarbonate 
of  soda  C^iss  to  water  3viij)  should  be  used  to  rinse  the  mouth  with 
several  times  during  the  day  (a  teaspoonful  of  the  solution  may  be 
swallowed  each  time  it  is  used),  and  an  antiseptic  tooth-powder  should 
be  used  morning  and  night.  By  this  means  the  neuralgia  is  con- 
trolled, and  the  teeth  in  a  short  time  placed  in  a  condition  to  admit  of 
their  being  partially  cleansed,  and  filled  as  before  indicated. 

Active  constitutional  syphilis  is  diagnosticated  by  the  usual  eruption 
upon  the  face,  neck,  and  chest,  and  the  mucous  patches  upon  the  lips, 
inside  of  the  cheeks,  or  upon  the  tongue. 

When  these  symptoms  are  present,  the  general  practitioner  should 
be  consulted  at  once,  before  any  dental  work  is  undertaken.  If, 
however,  for  any  reason  slight  local  treatment  is  at  once  necessary, 
great  care  must  be  taken  to  prevent  inoculating  one's  self  or  any 
subsequent  patient. 

In  the  first  place,  the  operator  should  carefully  examine  his  hands 
to  see  if  any  abrasion  of  the  skin  is  to  be  found.  Should  such  be 
the  case,  flexible  collodion  should  be  applied  as  a  protection  to  the 
parts,  and  after  the  operation  all  instruments  should  be  thoroughly 
disinfected.  This  should  include  not  only  the  steel  instruments,  but 
the  mouth-mirror  (usually  neglected),  and  the  glass  from  which  the 
patient  may  have  taken  water.  The  napkins  used  should  be  burned. 
If  no  physician  be  at  hand  or  easy  of  consultation,  one  may  prescribe 
the  classical  remedy — bichlorid  of  mercury,  one-sixteenth  grain, 
three  times  a  day.  This  should  be  given  until  the  eruption  and 
mucous  patches  have  disappeared.  Even  then  severe  dental  opera- 
tions should  not  be  performed,  but  any  carious  teeth  should  be  filled 
temporarily,  as  in  the  other  cases. 

The  effect  of  mercury  upon  the  periosteum,  especially  of  the 
mouth,  is  such  as  to  render  it  susceptible  to  the  slightest  undue  irri- 
tation ;  consequently,  while  a  patient  is  under  mercurial  treatment, 
great  care  should  be  exercised  in  any  work  done  upon  the  teeth. 

Should  any  periosteal  disturbance  follow  this  mild  treatment,  or 
present  at  any  subsequent  time,  in  the  mouth  of  such  patient,  iodid 
of  potassium  should  be  given,  beginning  with  ten-grain  doses  thrice 
daily,  increasing  the  dose  one  grain  daily,  until  the  progress  of  the 
disease  locally  has  been  checked.  The  differential  diagnosis  between 
mucous  patches  and  canker  sores — water  cancer — is  of  great  impor- 


I  go  DENTAL  PATHOLOGY  AND  PRACTICE. 

tance.  In  mucous  patches,  an  indurated  base  and  raised  edges  are 
always  present,  with  a  color  slightly  darker  than  the  membrane 
around  them  ;  while  in  canker  sores  these  conditions  are  absent,  and 
instead  the  base  is  soft,  slightly  lighter  in  color  than  the  surrounding 
membrane,  and  the  edges  are  even  with  it. 

The  presence  of  canker  sores  in  the  mouth  indicates  either  a  con- 
dition of  the  system  below  that  which  would  be  considered  as  good 
health,  due  perhaps  to  indigestion  or  functional  disorder  of  some 
other  organ  or  organs,  or  that  a  local  injury  from  the  tooth-brush  or 
some  artificial  appliance  worn  in  the  mouth  has  been  received. 

In  anemia  as  generally  presenting  in  scrofulous  conditions  or  in 
patients  suffering  from  malarial  poison,  it  is  not  safe  to  perform 
long  and  tedious  operations  upon  the  teeth.  Undue  irritation  of  the 
periosteum  in  such  cases  is  not  readily  relieved,  but  continues 
until  perhaps  the  death  of  the  pulp.  An  abscess  and  necrosis  of  the 
alveolus  follow.  These  are  cases,  again,  where  the  general  prac- 
titioner should  be  consulted  and  proper  restoratives  given.  In  case 
no  physician  be  at  hand  or  can  be  consulted  readily,  Scrofulous 
patients  should  be  advised  to  take  cod-liver  oil  in  tablespoonful  doses 
three  times  a  day  after  eating,  to  which  may  be  added  five  drops  of 
the  syrup  of  iodid  of  iron,  which  may  be  increased,  after  a  few  days, 
to  ten  drops,  if  the  patient  be  an  adult. 

In  persons  suffering  from  malarial  poisoning,  quinin  and  iron  are 
indicated.  The  quinin  may  be  given  either  in  liquid  form  or  in  cap- 
sules. The  latter  mode  is  preferable,  as  the  liquid  preparation  is 
usually  so  strongly  acid  that  injury  to  the  teeth  is  to  be  feared.  From 
two  to  four  grains,  three  times  a  day,  should  be  given. 

There  are  several  excellent  preparations  of  iron,  any  one  of  which 
is  of  undoubted  value  in  these  anemic  cases,  such  as  tincture  of  the 
chlorid  of  iron,  ammonio-citrate  of  iron,  dialyzed  iron,  syrup  of 
iodid  of  iron,  etc.  For  its  rapid  restorative  properties  the  tincture 
of  the  chlorid  is  often  preferred  ;  it  has  its  disadvantages,  however. 
As  its  name  indicates,  it  is  strongly  acid,  and  frequently  does  great 
harm  to  the  dental  organs.  For  this  reason,  some  one  of  the  other 
preparations  is  used,  unless  the  case  is  an  urgent  one  In  such 
event,  and  when  quinin  is  given  in  liquid  form,  the  mouth  should  be 
most  thoroughly  washed  out  at  intervals  of  not  more  than  one  hour 
during  the  day  with  the  solution  of  bicarbonate  of  soda,  above 
recommended,  and  the  teeth  thoroughly  cleansed  with  an  alkaline 
tooth-powder  twice  a  day. 

All  teeth  with  carious  cavities  should  be  treated  locally  with  the 
soda  until  they  can  be  partially  prepared  for  filling,  and  temporary 
fillings  placed  in  them  until  the  general  health  of  the  patient  will 
admit  of  more  permanent  work. 


STOMATITIS  ;    VARIETIES,   CAUSES,  AND    TREATMENT.  IQI 

CHAPTER   XX. 

STOMATITIS  ;    VARIETIES,   CAUSES,   AND   TREATMENT. 

Inflammation  of  the  mucous  membrane  of  the  oral  cavity  is  a 
common  and,  in  some  instances,  a  very  distressing  disease.  During 
infancy  the  mouth  is  subject  to  a  variety  of  inflammatory  conditions 
which  are  seldom  seen  by  dental  surgeons,  but  the  effects  of  which 
are  often,  in  after-years,  brought  to  his  notice  in  the  form  of  imper- 
fect enamel  of  the  teeth,  a  study  of  which  will  be  found  in  Chapters 
V  and  VI. 

Those  varieties  which  come  under  the  care  of  the  dental  surgeon 
are,  mercurial,  spontaneous,  and  aphthous  stomatitis,  ulitis,  and  gin- 
givitis. 

Mercurial  stomatitis  is  the  result  of  ptyalism  (salivation).  Mer- 
cury, when  taken  in  large  doses  or  oft-repeated  small  doses,  mani- 
fests its  presence  in  the  system  by  a  persistent,  severe  irritation  of 
the  salivary  glands,  causing  them  to  secrete  saliva  to  an  extraordinary 
extent,  producing  a  coppery  taste,  swelling  and  sponginess  of  the 
gums,  and,  unless  checked,  involving  the  entire  mucous  membrane 
of  the  mouth,  including  the  tongue.  Such  cases  are  much  more 
severe  and  promise  less  from  treatment,  so  far  as  the  teeth  are  con- 
cerned, if  they  have  previously  been  neglected  and  tartar  has  been 
allowed  to  collect  upon  them. 

The  treatment  consists  in  thoroughly  removing  all  foreign  accumu- 
lations from  the  teeth,  repeating  the  operation  every  two  or  three  days 
until  a  decided  change  for  the  better  is  manifest.  In  the  mean  time 
the  mouth  should  be  rinsed  every  half-hour  with  a  solution  of  soda 
bicarbonate,  one  drachm  to  eight  ounces  of  water,  to  which  may  be 
added,  with  advantage,  three  grains  of  salicylic  acid.  The  soda  neu- 
tralizes the  acid  condition  always  present,  and  the  salicylic  acid  checks 
fermentation.  The  necks  and  roots  of  the  teeth  which  have  become 
denuded  are  thus  prevented  from  becoming  so  very  sensitive,  as  they 
are  apt  to  do  in  such  conditions.  Milk  of  magnesia  with  equal  parts 
of  water  may  be  substituted  for  the  soda  bicarbonate. 

lodin  will  produce  salivation  in  some  persons,  although  of  a  less 
severe  type  than  that  resulting  from  mercury. 

Spontaneous  stomatitis  is  a  condition  of  inflammation  of  the  mouth 
which  has  apparently  no  local  irritating  cause.  It  is  characterized  by 
a  thickened,  puffy  feeling  of  the  mucous  membrane,  which  becomes 
in  a  few  hours  very  sensitive  to  the  touch,  even  of  food,  in  eating, 
with   a   constant   smarting  pain.       This    occurs    upon    one   side   of 


192  DENTAL    PATHOLOGY   AND    PRACTICE. 

the  roof  of  the  mouth,  then  sometimes  upon  the  other,  or  upon 
both  sides  at  the  same  time,  the  lower  jaw  being  seldom  attacked. 
This  is  undoubtedly  the  local  manifestation  of  some  constitutional 
disturbance  induced  by  a  slight  injury  to  the  mouth,  with  tooth-pick, 
tooth-brush,  hot  drinks,  or  by  biting  upon  some  hard  substance 
against  the  gum. 

The  treatment  consists  in  thorough  cleansing  of  the  mouth  and 
teeth,  and  painting  the  inflamed  parts  with  tincture  of  iodin,  or 
spraying  them  with  the  following  : 

R — Tannic  acid, 
Carbolic  acid, 
Tr.  iodin,  aa  5  ss  ; 
Glycerin, 

Distilled  water,  aa  .^  ss. 
M. 

This  treatment  may  be  repeated  every  day  until  relief  is  obtained. 

Aphthous  stomatitis  (canker  sores)  is  characterized  by  the  appear- 
ance of  ulcerated  patches,  sometimes  of  the  size  of  a  mustard-seed  and 
thence  to  the  size  of  a  silver  five-cent  piece.  They  are  first  noticed 
as  slight  translucent  elevations  upon  the  gums,  tongue,  and  the  inside 
of  the  lips  and  cheeks,  and  are  filled  with  a  watery  liquid.  After 
a  few  hours,  these  vesicles  open  either  spontaneously  or  are  broken 
by  mastication,  etc.,  when  it  is  discovered  that  penetrating  to  the 
submucous  tissue  is  an  ulceration,  which  has  been  effected  by  the 
contents  of  the  vesicle  before  it  was  opened.  These  aphthous 
ulcers  are,  until  they  begin  to  mend,  usually  very  painful,  the  pain 
being  of  the  smarting  variety. 

As  to  the  etiology  of  canker  sores,  it  seems  that  it  is  not  well  under- 
stood by  the  profession,  the  only  cause  assigned  being  general  debil- 
ity or  a  low  physical  condition,  due  to  indigestion,  etc.  There  is  no 
doubt  that  this  is  a  great  factor  in  their  production,  but  I  have  long 
believed  that  some  local  disturbance,  such  as  injury  of  the  parts  with 
the  tooth-brush  or  by  some  other  means,  has  much  to  do  with  pro- 
ducing them.  In  fact,  I  have  known  many  cases  where  an  injury 
with  the  tooth-brush  or  some  artificial  appliance  has  caused  them, 
where  none  of  the  constitutional  troubles,  usually  given  as  their 
cause,  were  present. 

The  treatment  consists  in  washing  them  with  warm  water,  drying 
the  surface  as  well  as  practicable,  and  with  a  pellet  of  cotton,  satu- 
rated with  a  solution  of  ten  grains  of  permanganate  of  potash  to 
one  ounce  of  water,  thoroughly  impressing  the  ulcerated  surface  with 
the  drug,  by  holding  the  pellet  upon  it  for  half  a  minute  or  more. 
Two  or  three  applications  are  usually  sufficient  to  effect  a  cure. 
Nitrate  of  silver  (lunar  caustic)  is  a  very  good  remedy,  as  is  also  burnt 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    I93 

alum.      Pure  carbolic  acid  arid  wood  creasote  are  recommended  by 
some  practitioners  as  efficacious  in  the  treatment  of  these  ulcers. 

Ulitis  is  a  circumscribed  inflammation  of  the  gums,  caused  by  the 
presence  of  foreign  substances  (tartar)  upon  the  necks  and  roots  of 
teeth. 

Gingivitis  is  an  inflammation  of  the  gingival  margins  of  the  gums, 
due  to  the  same  causes  as  ulitis. 

The  treatment  in  each  consists  in  thoroughly  removing  all  foreign 
accumulations  from  the  teeth  and  keeping  them  clean.  Where 
excessive  inflammation  is  present,  the  parts  may  be  painted  with 
tincture  of  iodin  to  advantage.  Everything,  however,  depends 
upon  cleanliness  of  the  teeth.  If  the  gums  become  lacerated  in 
removing  the  tartar,  spraying  them  with  the  recipe  above  given  will 
be  found  beneficial. 


CHAPTER   XXI. 

CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.* 

Modern  histologists  agree  that  the  animal  body  is  composed  of 
only  four  varieties  of  tissues, — viz,  connective,  muscle,  nerve,  and 
epithelial.  All  attempts  at  basing  a  nomenclature  of  tumors  on 
strictly  anatomical  or  histological  grounds  must  be  in  agreement 
with  this  division  of  the  normal  tissues.  In  fact,  there  is  not  a 
single  morbid  growth  to  be  found  which  does  not  have  an  analogue 
in  some  physiological  tissue.  Among  the  four  varieties,  it  is  only 
the  connective  that  carries  blood-  and  lymph-vessels.  Muscle-fibers 
and  epithelia  are  destitute  of  vessels,  being  supplied  with  nourish- 
ment by  the  surrounding  and  subjacent  layers  of  connective  tissue,  or 
rather  the  vessels  contained  therein. 

The  nerve-fibers  are  surrounded  by  vascularized  connective  tissue, 
while  the  gray  substance  of  the  nerve-centers  is  considerably  mixed 
with  it,  although  a  satisfactory  distinction  between  the  gray  sub- 
stance and  this  tissue — the  so-called  neuroglia — has  never  been  made. 
The  normal  connective  tissue  in  its  perfect  development  appears  in 
four  varieties, — viz,  the  myxomatous,  the  fibrous,  the  cartilaginous, 
and  the  osseous.  In  accord  with  this  subdivision,  we  find  a  number 
of  varieties  of  tumors  which  are  composed  entirely  of  a  myxoma- 
tous, fibrous,  cartilaginous,  or  bony  tissue,  being  termed  myxoma, 
fibroma,  chondrorna,  and  osteoma.     These  are  the  representatives  of 

*Heitzmann  and  Abbott,  Dental  Cosmos,  1888 
14 


194  DENTAL    PATHOLOGY   AND    PRACTICE. 

a  type  of  tumors  known  clinically  as  benign,  since  they  grow  very 
slowly,  do  not  cause  pain,  do  not  ulcerate  except  after  local  injuries, 
and  do  not  produce  secondary  tumors  in  internal  organs,  and  even 
after  many  years'  growth  never  cause  death  directly. 

Fat-tissue  is  a  sub-variety  of  myxomatous,  and  tumors  largely 
composed  of  such  tissue  are  termed  lipoma.  If  blood-  or  lymph- 
vessels  are  abundant  in  a  tumor,  it  is  called  vascular,  or  an  angioma. 
If  muscles  enter  the  structure  of  the  tumor  we  speak  of  it  as  a  myoma, 
and  if  nerve-fibers  are  present  in  great  numbers  the  designation  is 
neuroma. 

In  all  these  instances  more  or  less  fibrous  connective  tissue  (the 
carrier  of  blood-vessels)  enters  into  the  architecture  of  the  tumor, 
and  even  in  certain  varieties  of  angioma,  the  so-called  cavernous — 
the  fibrous  connective  tissue  bounding  the  caverns  filled  with  venous 
blood — carry,  as  a  rule,  capillary  blood-vessels.  According  to  the 
prevailing  structure  present,  we  designate  a  given  tumor  ;  as  a  myo- 
fibroma if  the  muscle-tissue  predominates,  or  fibro-myoma  if  the 
fibrous  connective  tissue  is  in  excess  over  the  muscle-tissue.  Here 
again  we  have  four  typical  varieties  of  tumors,  which  we  call  benign 
from  a  clinical  point  of  view. 

The  unripe  or  embryonal  condition  of  all  forms  of  connective  tissue 
is  termed  indifferent  or  medullary.  Tumors  that  are  built  up  of 
.such  tissue  belong,  as  Virchow  showed  many  years  ago,  to  the  group 
of  connective-tissue  tumors,  for  which  he  proposed  the  term  sarcoma. 
These  grow  rapidly,  causing  more  or  less  pain  and  sometimes  ulcera- 
tion, besides  being  very  prone  to  excite  the  formation  of  secondary 
tumors  in  internal  organs,  thus  directly  leading  to  the  death  of  the 
patient.  Clinically  they  are  known  as  malignant  tumors.  Since  the 
term  would  indicate  a  fleshy  tumor,  we  propose  to  abandon  the  name 
sarcoma  and  substitute  for  it  the  word  myeloma,  which  really  desig- 
nates what  the  tumor  is  composed  of,  viz,  medullary  tissue. 

It  is  impossible  to  tell  why  a  myeloma  should  possess  properties 
which  enable  it  to  transform  all  sorts  of  tissues  and  organs  into  its  own 
peculiar  structure.  Neither  do  we  understand  the  reason  why  mye- 
loma appears  mainly  in  children  and  young  persons,  in  contradis- 
tinction to  carcinoma,  which  is,  in  the  great  majority  of  cases,  a  disease 
of  advanced  life.  The  main  constituents  of  myeloma  are  globular  or 
spindle-shaped  corpuscles,  with  very  little  intervening  basis-substance. 
This  feature  furnishes  the  most  important  point  for  a  differential 
diagnosis  between  the  benign  and  malignant  forms  of  tumors  of  the 
connective-tissue  series.  There  are,  however,  transitional  forms  in 
which  portions  of  the  new  growth  are  well  supplied  with  basis-sub- 
stance of  any  of  the  four  types  named  above,  while  other  portions  are 
composed  mainly  of  medullary  tissue.     It  also  occurs  that  we  find 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    I95 

nests  of  medullary  corpuscles  in  the  middle  of  a  benign  tumor,  usually 
in  the  neighborhood  of  the  sources  of  nutrition, — i.e.,  around  the 
blood-vessels. 

In  accordance  with  the  foregoing  nomenclature,  tumors  of  such  a 
mixed  character  are  designated  as  myxo-myeloma,  fibro-myeloma, 
chondro-myeloma,  and  osteo-myeloma.  Combinations  like  these 
always  mean  a  tumor  which  grows  rapidly,  is  prone  to  recur  after 
operations  not  skillfully  performed,  and  gradually  to  assume  the 
characteristic  features  of  purely  malignant  myeloma.  In  such  cases 
attempts  at  eradication,  such  as  cauterization,  or  injuries  of  any  nature, 
hasten  the  transformation  of  a  slightly  malignant  growth  into  one 
markedly  so. 

The  fourth  group  of  tissues,  the  epithelial,  never  produces  a  tumor 
alone,  since  it  is  invariably  combined  with  more  or  less  vascularized 
connective  tissue.  If  the  latter  produces  papillary  elevations,  covered 
on  the  outer  surface  with  stratified  epithelium,  we  term  it  a  warty 
growth,  or  papilloma.  If  the  epithelium  produces  acinous  or  tubular 
prolongations  into  the  depth  of  the  connective  tissue,  we  have  a 
glandular  tumor,  or  adenoma.  Both  of  these  types  are  clinically 
benign  ;  whereas  the  third  type,  in  which  epithelial  and  connective 
tissue  are  intermixed  without  any  regularity,  is  designated  cancer, 
or  carcinoma,  being  decidedly  malignant.  Again  we  are  unable  to 
say  wherein  rests  this  pronounced  capacity  of  carcinoma  to  infect  all 
sorts  of  neighboring  tissues,  more  especially  the  adjacent  lymph- 
ganglia,  and  to  transform  normal  tissues  into  its  own  substance. 

A  few  years  since,  Scheiirlen,  of  Wiirtemberg,  Germany,  demon- 
strated the  presence  of  bacilli  of  a  characteristic  form  and  growth, 
which  he  claims  to  be  the  elements  which  cause  cancer.  Schill,  of 
Dresden,  claims  priority  for  this  discovery,  and  maintains  that  bacilli 
similar  to  those  of  cancer  are  also  to  be  found  in  sarcoma  or  myeloma. 

One  large  group  of  tumors  is  represented  by  closed  cavities  filled 
with  liquid  or  semi-solid  contents,  the  so-called  cysts.  Such  growths 
arise  mainly  in  organs  which,  in  a  physiological  condition,  contain 
epithelial  or  glandular  structures.  In  many  instances  a  new  forma- 
tion of  glandular  tissue  (an  adenoma)  precedes  the  appearance  of  a 
cyst.  Closed  cavities,  however,  are  not  infrequently  found  in  both 
benign  and  malignant  types  of  connective-tissue  tumors,  and  in  such 
cases  we  are  in  the  dark  as  to  the  origin  of  the  cysts,  and  designate 
the  new  formation  cysto-fibroma,  cysto-osteoma,  cysto-myeloma, 
etc. 

As  to  the  cause  of  tumors,  the  theory  of  Cohnheim  suggests  mis- 
placed embryonal  germs.  This  brilliant  theory  was  subsequently 
limited  by  its  author  to  certain  varieties,  such  as  primary  cancer  in 
the  bone  or  in  lymph  ganglia.     Unfortunately,  however,  this  theory 


196  DENTAL    PATHOLOGY   AND    PRACTICE. 

cannot  be  proven,  either  by  direct  observation  or  by  experiments 
upon  animals.  We  are  positive  of  only  one  fact,  viz,  that  an  acute 
traumatism  or  oft-repeated  slight  injuries — in  short,  a  local  irritation — 
furnishes  in  many  instances  the  explanation  of  the  appearance  of 
abnormal  growths.  In  several  of  our  specimens  the  trace  of  a  previous 
traumatism  was  found  under  the  microscope,  in  the  shape  of  clusters 
of  pigment,  the  result  of  a  hemorrhage  that  must  have  occurred  long 
before.  Inflammations  of  the  gum  and  the  pericementum  are 
acknowledged  to  be  fertile  sources  of  tumors,  as  well  as  traumatisms 
or  other  irritations. 

Our  observations  are  based  upon  seventeen  different  tumors. 
These  embrace  the  most  common  types  of  both  benign  and  malig- 
nant tumors  of  the  jaws.  The  great  majority  were  primary  on  the 
jaws,  and  only  two  cases,  one  of  myeloma  and  one  of  carcinoma, 
are  secondary  to  the  jaws  by  contiguity.  We  excluded  from  our 
consideration  all  tumors  of  the  teeth  proper. 

I. — Myxoma. 

This  variety  of  tumor  is  not  rare  on  the  gums  around  the  teeth. 
The  specimen  under  observation  is  of  the  size  of  a  robin's  egg,  with 
a  nodulated  surface,  originally  of  a  blood-red  color,  of  rather  soft 
consistence,  and  grew  upon  the  gum  of  the  lower  jaw,  left  side, 
between  the  second  bicuspid  and  first  molar.  It  recurred  at  every 
pregnancy,  this  being  the  third,  in  the  mouth  of  a  lady  aged  about 
twenty-six  years.  Tumors  had  been  removed  from  the  same  locality 
four  different  times,  when  the  patient  was  a  girl  from  twelve  to  four- 
teen years  of  age. 

With  low  powers  of  the  microscope  the  raspberry  or  papillary 
appearance  was  well  defined  upon  the  surface,  as  represented  in  Fig. 
78.  The  surface  is  coated  with  a  single  row  of  columnar  epithelium, 
the  boundary  of  which  toward  the  subjacent  connective  tissue  is  in- 
distinct,— so  much  so  that  the  lowest  portions  of  columnar  epithelia 
and  the  bodies  wedged  in  between  them  blend  with  the  adjacent 
layers  of  medullary  tissue.  The  so-called  structureless  layer  can  be 
made  out  in  but  few  places.  The  main  mass  of  the  growth  consists  of 
an  extremely  delicate  net- work  of  fibrous  connective  tissue  with  inter- 
spersed nuclei,  mainly  at  the  points  of  intersection.  The  meshes  of 
this  net-work  contain  as  a  rule  only  one  medullary  corpuscle  ;  but  near 
the  surface  such  corpuscles  are  present  in  such  numbers  that  the 
reticulum  is  rendered  invisible.  The  corpuscles  are  comparatively 
small  and  nearly  compact  near  the  periphery,  while  they  are  granular 
and  markedly  larger  in  the  deeper  portions.  The  outermost  portions 
of  the  tumor,  owing  to  the  abundance  of  medullary  corpuscles,  have 
the  character  of  a  myeloma  ;  but  the  gradual  appearance  of  a  myxo- 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    1 97 


matous  basis-substance  in  the  deeper  portions  proves  that  the  tissue 
is  myxomatous,  and  the  clusters  of  the  medullary  corpuscles  merely 
signify  a  rapid  growth  at  the  surface. 

Fig.  78. 


Myxoma  or  Granuloma  of  the  Gum  of  the  Lower  Jaw. 
Z,,  longitudinal,  7",  transverse  section  of  the  papillae  on  the  surface;  71/,  myxomatous  tissue; 
F,  blood-vessels  traversing  the  myxomatous  tissue.     Magnified  100  diameters. 


igo  DENTAL   PATHOLOGY   AND    PRACTICE. 

A  striking  feature  of  this  growth  is  the  large  number  of  wide 
capillary  blood-vessels,  which  run  mostly  in  a  vertical  direction  to  the 
surface,  and  therefore  appear  in  transverse  sections  where  the  pa- 
pillae are  cut  transversely.  The  arrangement  of  the  capillaries  in  a 
tassel-like  manner  seems  to  account  for  the  papillary  or  nodular 
architecture  of  the  surface.  The  so-called  proud-flesh  or  granula- 
tion-tissue of  suppurating  wounds  has  the  same  structure  as  the 
tumor  under  consideration,  and  some  authors  speak  of  a  granuloma 
corresponding  to  the  structure  of  a  myxoma,  but  produced  by  an 
inflammatory  process.  In  the  deeper  portions  of  the  tumor  delicate 
bundles  of  fibrous  connective  tissue  are  visible,  and  most  of  the 
vessels  are  accompanied  by  tracts  of  such  tissue,  by  which  an  adven- 
titial coat  is  produced,  even  around  the  capillaries,  which  is  not  visi- 
ble in  normal  tissue.  In  the  deepest  portions  the  fibrous  connective 
tissue  is  rather  abundant,  the  medullary  corpuscles  being  at  the  same 
time  scanty,  and  the  blood-vessels  bearing  the  character  of  veins. 

Growths  of  this  kind  are  sometimes  seen  arising  from  the  gum  be- 
tween the  teeth,  owing  to  some  constant  irritation.  It  is  quite  possi- 
ble that  the  lady  in  whose  mouth  the  tumor  grew  irritated  her  gums, 
perhaps  mechanically,  by  allowing  particles  of  food  or  tartar  to  accu- 
mulate. The  microscope  does  not  enable  us  to  draw  sharp  boundary 
lines  between  products  of  inflammation  and  tumors  proper.  Good 
authorities — for  instance,  Virchow — claim  that  a  tubercle  or  a  gumma 
due  to  syphilis  is  a  tumor  composed  of  granulation-tissue,  and  is 
therefore  granuloma,  although  most  modern  writers  agree  that  the 
nodules  mentioned  are  caused  by  local  inflammation. 

II. — Myxo-Fibroma. 

This  variety  of  benign  tumors  is  likewise  known  as  occurring  fre- 
quently, taking  issue  either  from  the  gums  or.  the  periosteum.  Its 
consistence  is  harder  than  that  of  a  pure  myxoma,  and  softer  than 
that  of  a  pure  fibroma.     (See  Fig.  79.) 

The  illustration  is  taken  from  the  deepest  portions  of  the  myxoma 
above  described.  It  consists  of  interlacing  bundles  of  a  delicate 
fibrous  connective  tissue,  exhibiting  therefore  an  indistinct  reticular 
arrangement.  The  meshes  between  the  bundles  are  filled  with  a 
finely-granular  basis-substance,  in  which  medullary  corpuscles  are 
stored  up  in  varying  numbers.  The  blood-vessels  are  comparatively 
scanty,  consisting  of  capillaries  and  veins,  all  of  which  are  sur- 
rounded by  a  distinct  layer  of  fibrous  connective  tissue.  The  endo- 
thelia  of  the  capillaries  are  unusually  thick  and  bulging  into  the 
lumen.  In  some  places  the  capillary  appears  to  be  supplied  with 
two  or  more  endothelial  layers,  which  add  considerably  to  the  thick- 
ness of  the  vascular  wall.     The  specimen  affords  a  good  opportunity 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    I99 

for  the  study  of  the  manner  in  which,  first,  myxomatous  tissue  arises 
from  medullary,  and  fibrous  from  myxomatous,  a  process  which,  as 
is  well  known,  is  of  frequent  occurrence  in  the  history  of  develop- 
ment  of    normal  fibrous   connective  tissue.     At  first  the  tissue  is 


Myxo-Fibroma  of  the  Gum  of  the  Lowkr  Jaw. 

M,  myxomatous  tissue,  composed  of  delicate  fibrous  bundles  ;  M  i,  the  bundles  coarser, 
still  exhibiting  the  reticular  arrangement ;  71-/2,  the  fibrous  bundles,  broad,  inclosing  fields  of 
a  myxomatous  basis-substance  ;   K,  V,  large  capillary  blood-vessels.    Magnified  200  diameters. 


200  DENTAL   PATHOLOGY   AND    PRACTICE. 

apparently  nothing  but  an  aggregation  of  indifferent  or  medullary 
corpuscles,  the  tissue  nature  of  which  is  determined  only  by  the  fact 
that  all  the  corpuscles  are  united  with  one  another  by  means  of  deli- 
cate threads.  The  corpuscles  themselves  are  originally  small  homoge- 
neous lumps,  of  a  high  degree  of  refraction.  Soon  afterward  a  num- 
ber of  such  indifferent  corpuscles  assume  a  granular  appearance,  and 
between  them  an  extremely  delicate  reticulum  appears  as  the  first 
trace  of  a  reticular  structure.  Some  authors  have  noted,  at  this 
stage  of  development,  which  we  often  see  in  inflamed  tissue,  the  exist- 
ence of  an  adenoid  or  lymph-tissue,  by  which  designation  •  is  meant 
the  appearance  of  a  delicate  myxomatous  reticulum  In  the  next 
stage  many  of  the  medullary  corpuscles  are  transformed  into  a  myxo- 
matous basis-substance,  which  with  lower  powers  of  the  microscope 
looks  either  homogeneous  or  finely  granular.  Fields  of  such  trans- 
formed medullary  corpuscles  have  either  one  or  several  corpuscles 
unchanged,  and  are  bordered  by  a  delicate  fibrous  reticulum,  at  the 
points  of  intersection  of  which  small  oblong  or  globular  corpuscles 
are  seen.  In  this  stage  of  development  the  tissue  is  called  purely 
myxomatous. 

If,  by  a  further  splitting  up  of  the  medullary  corpuscles  into  deli- 
cate spindles,  the  fibrous  reticulum  is  augmented,  and  the  fields  of 
myxomatous  basis-substance  narrowed,  we  have  a  transition  from 
myxoma  into  myxo-fibroma,  and  this  transition  is  the  more  marked 
the  broader  the  bundles  of  fibrous  connective  tissue.  All  these 
stages,  to  be  sure,  cannot  be  traced  in  direct  transition  from  one 
into  another,  but  we  conclude,  from  observing  the  successive  portions 
of  the  same  tumor,  medullary  at  the  periphery  and  fibrous  at  the 
base,  that  the  former  are  the  youngest  and  least  developed,  and  the 
latter  the  oldest  and  most  advanced.  With  the  long-accepted  theory 
of  secretion  of  basis-substance,  we  were  at  a  loss  to  account  for  all 
these  phenomena  ;  whereas  the  theory  first  advanced  by  the  late 
Max  Schultze (1861),  known  as  the  "transformation  theory,"  renders 
the  formation  of  basis-substance  explicable,  provided  we  keep  in  mind 
that  it  is  nothing  but  protoplasm  altered  chemically. 

III. — Fibroma. 

Solid  and  dense  tumors  of  a  very  slow  growth,  starting  from  the 
periosteum  of  the  jaw-bones,  are  of  rather  frequent  occurrence  and 
well  known  to  surgeons.  The  name  given  to  them  was  * '  epulis, ' '  which 
means  a  tumor  growing  upon  the  gum.  Obviously  this  is  a  mis- 
nomer, since  we  know  that  tumors  of  this  description  take  issue  as  a 
rule  from  the  periosteum,  and  invade  the  gum  in  a  rather  secondary 
way.     One  of  the  striking  features  of  such  benign  tumors   is  the 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    20I 

presence  of  protoplasmic  masses  with  a  varying  number  of  nuclei, 
the  so-called  giant-cells  of  previous  pathologists.  They  are  present 
in  greatly  varying  numbers,  mainly  in  that  portion  of  the  tumor 
nearest  to  the  periosteum,  often  arranged  in  groups,  and  entirely 
absent  from  the  peripheral  portions  of  the  growth.  (See  Fig.  80.) 
When  such  bodies  are  visible,  they  are  as  a  rule  surrounded  by  em- 

FiG.  80. 


Base  of  Fibroma  with  Multinuclear  Bodies,  so-called  Giant-Cells. 

5',  spindle-shaped  medullary  corpuscles  ;  F,  fibrous  basis-substance  having  originated  from 
spindle-shaped  medullary  corpuscles ;  M,  multinuclear  body  retracted  from  the  surrounding 
medullary  tissue ;  Mi,  multinuclear  body  in  connection  with  large  medullary  or  endothelial 
elements.     Magnified  600  diameters. 


bryonal  tissue,  and  it  is  easy  to  observe  their  origin  from  a  varying- 
number  of  medullary  corpuscles.  The  latter  coalesce,  thereby  losing 
their  individual  boundary  lines,  and  produce  a  uniformly  granular 
mass  of  protoplasm,  in  which  we  recognize  either  scattered  nuclei 


202  DENTAL   PATHOLOGY   AND    PRACTICE. 

or  coarser  granules,  so-called  nucleoli.  Around  the  corpuscle,  which 
is  often  of  irregular  shape,  sending  offshoots  into  the  neighbor- 
ing medullary  tissue,  the  adjacent  medullary  corpuscles  produce  a 
kind  of  capsule,  between  which  and  the  multinuclear  bodies  a  gap 
is  not  infrequently  seen, — caused,  as  it  were,  by  the  shrinkage  of  the 
"  giant-cell." 

It  is  known  that  bodies  of  this  description  are  often  met  with  in 
the  normal  medullary  tissue  of  forming  and  growing  bone.  We 
often  find  them  in  those  bay-like  excavations  that  appear  in  the  ce- 
mentum  and  dentine  of  temporary  teeth  during  the  process  of  their 
absorption.  The  prevailing  idea  as  to  their  significance  is  that  they 
grow  by  the  coalescence  of  leucocytes  or  medullary  corpuscles  from 
without  into  the  cement  or  dentinal  tissue,  liquefying  and  breaking 
up  these  tissues  lying  in  their  way  ;  hence  their  name,  "  osteoclasts," 
or  "bone-breakers." 

We  must  disagree  decidedly  with  this  view,  since  we  have  seen 
multinuclear  protoplasmic  bodies  arising  from  the  living  matter  of 
cementum  and  dentine  itself,  after  the  dissolution  of  the  lime-salts 
and  the  liquefaction  of  the  basis-substance.  We  have  furthermore 
often  seen  such  bodies  in  the  medulla,  preceding  the  formation  of 
bone-tissue.  Since  the  territories  of  formed  bone-tissue  are  often 
transformed  into  such  multinuclear  bodies,  the  idea  becomes  admissi- 
ble that  they  can  appear  previous  to  development  of  the  osseous 
territory  ;  and  their  presence  in  the  periosteal  portion  of  fibrous 
tumors  is  consonant  with  this  view.  We  admit,  however,  that  this 
theory  does  not  account  for  the  presence  of  so-called  giant-cells  in 
every  instance,  since,  as  we  shall  show  later  on,  they  accompany 
blood-vessels,  and  are  known  to  exist  in  inflammatory  products, — 
for  instance,  in  tubercles. 

The  tumor  before  us  (Fig.  8i)  appeared  on  the  alveolar  process  of 
the  upper  jaw  in  the  shape  of  a  sessile  nodule,  the  size  of  half  a 
hickory-nut,  in  a  youth  about  twenty  years  of  age. 

The  surface  of  the  tumor  looked  comparatively  smooth  to  the 
naked  eye,  but  microscopical  specimens  show  remnants  of  the  pa- 
pillae of  the  gum,  rather  shallow  and  blunt,  and  some  distance 
apart.  The  outer  coating  is  made  up  of  stratified  epithelium,  whose 
layers  are  noticeably  diminished,  probably  owing  to  the  pressure  of 
the  growth  from  within.  The  first  row  of  columnar  epithelia  is  well 
marked  only  in  the  valleys  between  the  remnants  of  the  papillae, 
while  on  their  summits  the  first  row  is  composed  of  short  columnar, 
or  rather  cuboidal  epithelia.  In  these  places  the  epithelia  of  both 
the  first  and  the  adjacent  layers  exhibit  central  vacuoles,  or  plasmatic 
spaces,  from  which  the  nuclei  have  dropped  out. 

The   bundles    of   fibrous    connective    tissue    are   of    considerable 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    203 

breadth  throughout  the  mass  of  the  tumor,  but  their  breadth  increases 
•from  the  outer  to  the  deeper  portion.     The  protoplasmic  tracts  are 


Fibroma  of  the  Alveolar  Process  of  the  Upper  Jaw. 

E,  stratified  epithelium  of  the  gum  ;  P,  blunt  papillae  of  the  gum ;  Z.,  L,  longitudinal,  T,  T, 
transverse  sections  of  bundles  of  fibrous  connective  tissue;  C,  C,  capillary  blood-vessels. 
Magnified  200  diameters. 

well  marked  between  the  bundles,  both  in  longitudinal  and  transverse 
sections.     The  bundles  are  freely  decussating  or  interlacing,  by  which 


204  DENTAL   PATHOLOGY   AND    PRACTICE. 

is  produced  an  extremely  dense  trestle-work,  similar  to  that  of  the 
derma  of  the  skin.  The  vessels  are  scanty  throughout  the  tissue, 
and  consist  mainly  of  capillaries. 

At  the  outer  portion  of  the  tumor,  between  the  bundles,  small 
nests  of  medullary  tissue  are  discernible.  The  deepest  portions,  on 
the  contrary,  are  made  up  largely  of  medullary  tissue,  composed  of 
globular  and  spindle-shaped  corpuscles,  with  a  goodly  number  of 
interspersed  multinuclear  bodies.  The  latter  feature  does  not  mean 
a  transformation  from  the  benign  fibroma  into  a  malignant  myeloma, 
but  the  juvenile  condition  of  the  connective  tissue,  and  a  somewhat 
accelerated  growth  from  beneath,  as  was  proven  by  the  fact  that  the 
tumor  did  not  return  after  removal. 

IV. — LiPO-FlBROMA. 

In  our  collection  there  is  no  tumor  from  the  jaws  made  up  of  fat  to 
such  an  extent  as  to  warrant  a  diagnosis  of  lipoma.  One  specimen, 
however,  the  size  of  a  cherry,  removed  from  the  lower  jaw,  shows  a 
combination  of  fibrous  connective  with  fat  tissue,  and  thus  gives  the 
variety  expressed  in  the  title.  The  fat-globules  are  of  greatly  varying 
sizes,  and  either  arranged  in  groups  or  scattered  singly  in  the  con- 
nective tissue  ;  arteries  are  accompanied  by  rows  of  such  globules. 
Most  of  the  latter  contain  vacuoles  and  peculiar  star-shaped  forma- 
tions in  their  centers,  which  very  probably'  are  not  crystals  of  mar- 
garic  acid,  as  some  previous  observers  have  believed,  but  remnants 
of  protoplasm,  known  to  exist  in  each  fat-globule.     (See  Fig.  82.) 

The  connective  tissue  is  of  two  kinds,  viz,  partly  broad  and 
heavy  bundles,  and  partly  narrow  spindles,  not  arranged  in  distinct 
bundles.  These  two  varieties  are  intermixed  without  any  regular- 
ity throughout  the  entire  tumor,  the  latter  being  especially  con- 
spicuous in  the  neighborhood  of  the  fat-tissue,  where  it  produces  a 
thin  layer,  carrying  blood-vessels  between  the  fat-globules,  or  sur- 
rounds groups  of  them.  The  connective  tissue  contains  a  number 
of  clusters  of  medullary  corpuscles,  which,  if  flattened  out  and  ren- 
dered polyhedral  by  mutual  pressure,  present  the  aspect  of  endothelia, 
and  if  coalesced  into  one  mass  represent  multinuclear  bodies  or  giant- 
cells.  The  history  of  development  of  fat-tissue  demonstrates  that 
each  globule  of  a  larger  size  arises  from  a  number  of  medullary 
corpuscles,  which  are  transforrrted  chemically  into  fat,  whereas  the 
central  portions  remain  unchanged  protoplasm,  with  branching  off- 
shoots ;  much  on  the  plan  of  territories  with  central  cartilage  or 
bone-corpuscles.  Small  fat-globules  may  be  the  products  of  trans- 
formation of  single  medullary  corpuscles,  or  a  limited  number  thereof 
It  has  long  been  known  that,  in  animals  in  which  emaciation  is  in- 
duced  rapidly   by   starvation,    each   fat-globule    breaks   up    into    a 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    205 

number  of  medullary  corpuscles, — viz,  into  the  embryonal  material 
which  originally  gave  rise  to  the  formation  of  a  globule.  If  we  re- 
call the  fact  that  each  fat-globule  is  surrounded  by  a  thin  connective- 


FiG.  82. 


LiPO-FiBROMA  OF  Lower  Jaw. 

F  F,  fat-globules  ;  M,  clusters  of  medullary  corpuscles  ;  G,  multinuclear  body  or  giant-cell 
/I,  artery.    Magnified  200  diameters. 


2o6  DENTAL   PATHOLOGY   AND    PRACTICE. 

tissue  corpuscle,  invariably  supplied  with  a  nucleus,  fat  at  once 
appears  as  a  variety  of  myxomatous  tissue,  the  difference  being  only 
a  chemical  alteration  of  the  protoplasm  into  carbohydrates  or  fat, 
instead  of  a  mucoid  basis-substance. 

From  this  point  of  view,  the  clusters  of  medullary  or  endothelial 
corpuscles  would  simply  represent  a  pre-stage  of  future  fat-globules 
or  remnants  of  previous  ones.  Since  multinuclear  bodies  or  giant- 
cells  are  known  to  result  from  a  coalescence  of  medullary  or  endo- 
thelial corpuscles,  there  is  good  reason  to  assume  that  these  bodies 
likewise  would  represent  eventually  either  a  previous  or  a  past  stage 
of  fat-globules.  A  fat-globule,  according  to  our  view,  is  a  globular 
territory  with  a  central  protoplasmic  body,  growing  in  exactly  the 
same  manner  as  a  territory  of  myxomatous,  cartilaginous,  or  osseous 
tissue  ;  the  nucleus  always  belonging  to  the  capsule  around  the 
globule,  and  not  to  the  globule  itself  A  territory  of  any  of  the 
tissues  named  will  break  up,  in  the  physiological  process  or  during 
reduction  to  pathological  conditions,  into  clusters  of  medullary  cor- 
puscles, or  into  multinuclear  protoplasmic  bodies. 

V. — Angioma. 

A  boy,  eleven  years  of  age,  presented  himself  with  a  tumor  the 
size  of  a  small  hickory-nut  on  the  gum  of  the  lower  jaw,  occupying 
the  region  of  the  right  lateral  incisor  and  cuspid,  and  having  its  origin 
in  a  somewhat  narrow  pedicle  between  the  teeth.  The  surface  was 
nearly  smooth,  slightly  lobulated  ;  its  consistence  rather  soft,  and  it 
was  easily  compressible  ;  its  color  dark  red.  Pressure  with  the  finger 
rendered  the  tumor  pale,  considerably  diminishing  its  bulk  at  the 
same  time,  but  as  soon  as  the  pressure  ceased  the  previous  size  and 
color  returned.  Three  months  previously  a  similar  tumor  had  been 
removed  from  the  same  place,  but  it  almost  immediately  commenced 
to  grow  again  with  alarming  rapidity,  causing  a  slightly  uneasy 
feeling,  but  no  pain. 

Vertical  sections  through  the  body  of  the  tumor  revealed  the  fact 
that  its  interior  was  composed  mainly  of  blood-vessels,  but  that  its 
outer  and  inner  portions  differed  from  each  other  in  structure.  The 
former  exhibited  the  features  of  a  lobular,  the  latter  of  a  cavernous, 
angioma. 

A,  Lobular  Angioma. — The  surface  of  the  vascular  or  erectile  tumor 
is  covered  with  a  stratified  epithelium,  being  normal  in  its  breadth 
at  the  borders,  and  much  thinned  in  the  middle  portions  of  the 
tumor.  In  the  former  numerous  rather  shallow  papillae  are  visible, 
a  certain  number  of  which  are  united  into  a  group  by  deep  epithelial 
valleys.  In  the  central  portions  only  a  limited  number  of  layers  of 
cuboidal  epithelia  are  discernible,  the  deepest  layer  being  absent,  and 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    207 

replaced  by  medullary  corpuscles  to  such  an  extent  that  no  boundary 
line  could  be  made  out  between  the  epithelium  and  the  subjacent 
connective  tissue.     (See  Fig.  83. ) 


Fig.  83. 


Lobular  Angioma  of  the  Gum  of  the  Lower  Jaw. 

EP  stratified  epithelium  whose  columnar  epithelia  toward  the  right  side  are  breaking  up 
into  medullary  corpuscles  ;  EN,  endothelial  layer  traversed  by  radiating  tracts  of  a  delicate 
fibrous  connective  tissue;  C,  capillary  blood-vessels  in  the  endothelial  layer;  Z., /.,  lobules 
composed  mainly  of  capillary  blood-vessels.    Magnified  200  diameters. 


2o8  DENTAL   PATHOLOGY    AND    PRACTICE. 

The  connective-tissue  layer  beneath  the  epithehum  is  made  up  of 
nucleated  granular  corpuscles,  closely  packed  together, — so  much 
so  that  they  flatten  each  other  into  broad  spindles.  Bodies  of  this 
description  are  termed  endothelia.  A  limited  number  of  tumors  of 
this  variety  have  been  known  since  Bizzoziro,  of  Italy,  drew  attention 
to  their  occurrence,  and  dubbed  them  endothelioma.  They  are 
usually  found  in  connection  with  lipoma  and  angioma. 

The  endothelia  appear  to  be  arranged  in  clusters,  between  which 
delicate  tracts  of  a  fibrous  connective  tissue  run  in  a  somewhat 
radiating  order,  which  tracts,  if  examined  with  higher  powers  of  the 
microscope,  appear  to  be  made  up  of  narrow,  partly-nucleated  spin- 
dles. The  tracts  spread  toward  the  periphery  in  a  fan  shape,  and 
no  clear  distinction  is  possible  here  between  the  broad  spindles  of  the 
endothelia  and  the  narrow  spindles  of  the  tracts. 

Some  distance  below  the  epithelia,  or  close  beneath  them,  a  large 
number  of  capillaries  are  seen  cut  in  longitudinal,  oblique,  and  trans- 
verse sections,  which  means  that  these  blood-vessels  are  coiled  up 
into  a  lobular  shape.  Between  the  lobules  there  are  either  tracts  of 
endothelia  mixed  with  fibrous  connective  tissue  or  bundles  of  the 
latter  alone,  and  these  interstitial  tracts  bear  capillaries  of  their 
own,  independently  of  those  within  the  lobules. 

The  most  striking  feature  in  the  endothelial  layers  is  the  formation 
of  the  red  blood-corpuscles  and  blood-vessels.  At  first  isolated 
lumps  appear  in  the  endothelia,  characterized  by  a  high  degree  of 
refraction,  and  yellow  in  color.  They  are  smaller  than  red  blood- 
corpuscles,  and  are  known  by  the  name  of  "  hsematoblasts."  In- 
creasing in  size,  they  assume  the  appearance  and  structure  of  red 
blood-corpuscles.  Clusters  of  haematoblasts,  or  fully-formed  red 
blood-corpuscles,  are  surrounded  by  circular  tracts  of  endothelia, 
which,  being  hollowed  out  in  part,  lead  to  the  formation  of  capillaries 
already  filled  with  blood,  while  a  number  of  endothelia  of  rather 
large  size  furnish  their  walls.  Thus  the  formation  of  red  blood- 
corpuscles  precedes  that  of  blood-vessels,  as  stated  some  fifty-odd 
years  ago  by  Rokitansky,  of  Vienna.  Thus  it  also  becomes  plain 
that  the  tissue  form  termed  endothelioma  is,  at  least  in  many 
instances,  a  pre-stage  of  angioma.  Obviously  the  newly-formed 
blood-vessels,  though  containing  blood-corpuscles  from  the  very  issue, 
are  closed  tubes  or  saccules,  which  later,  through  a  continued 
vacuolation  of  the  endothelia,  inosculate  with  already-formed  blood- 
vessels ;  their  tenants,  the  blood-corpuscles,  entering  into  the  circu- 
lation. 

B,  Cavernous  Angio^na. — The  lower  portions  of  the  tumor  under 
consideration  have  a  different  structure,  gradually  blending  with 
that   of  lobular  angioma.      Here  we  notice    large   cavities,   at  first 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    20q 

lined  by  several  layers  of  endothelia,  and  containing  a  varying 
number  of  red  blood-corpuscles,  until  eventually  very  large  spaces 
make  their  appearance,  filled  with  red  blood-corpuscles  ;  and  thus 
the  character  of  a  cavernous  angioma  is  established.     (See  Fig.  84.) 

Fig.  84. 


Cavernous  Angioma  from  the  Base  of  a  Vascular  Tumor  of  the  Gum. 

C,  C,  cavernous  spaces  filled  with  venous  blood ;  K,  K  capillary  blood-vessels  of  the  tra- 
beculse  bounding  the  cavities;  £,  E,  endothelia  in  transition,  partly  into  myxomatous  and 
partly  into  fibrous  connective  tissue.    Magnified  200  diameters. 

15 


2IO  DENTAL    PATHOLOGY   AND    PRACTICE. 

We  observe  tracts  of  endothelia  accompanied  by  a  delicate  fibrous 
connective  tissue,  with  irregular  calibers,  in  which  liquefaction  of  a 
certain  number  of  endothelia  has  taken  place,  as  indicated  by  their 
hydropic  condition,  to  such  an  extent  that  only  a  delicate  frame- 
work of  previous  endothelia  is  discernible.  A  certain  number  of 
endothelia  also  have  been  transformed  into  red  blood-corpuscles  ; 
another  set  furnishes  colorless  blood-corpuscles,  or  possibly  these 
arise  from  the  nuclei  of  previous  endothelia.  This  process  is  known 
to  histologists  by  the  term,  "  vacuolation  of  the  endotheha."  The 
openings  at  first  are  very  irregular,  'being  bounded  by  several  layers 
of  endothelia,  and  it  sometimes  occurs  that  tolerably  well-formed 
calibers  of  the  same  vessel  are  connected  with  one  another  by  narrow 
canals,  owing  to  the  presence  of  endothelia  only  slightly  changed. 
Blood-corpuscles  may  be  seen  in  one  part,  while  they  are  absent 
in  another,  so  long  as  the  vessels  are  not  complete.  The  remaining 
endothelia  are  large  and  supplied  with  oblong  nuclei  of  considerable 
size. 

Fully-formed  cavities  in  connection  with  the  physiological  vessels 
are  characterized  by  smaller  endothelia,  not  surpassing  in  size  those 
of  normal  veins.  The  trabeculae  inclosing  the  venous  cavities  are 
made  up  of  fibrous  connective  tissue,  carrying  their  own  capillary 
blood-vessels.  In  many  places,  however,  even  the  trabeculae  are 
made  up  of  endothelia,  and  it  is  easy  of  demonstration  that  the  en- 
dothelia are  merely  the  medullary  or  embryonal  stage  of  connective 
tissue,  since  we  can  trace  its  transformation  into  both  myxomatous 
and  fibrous  connective  tissue.  This  portion  of  the  tumor  contains 
solid  masses  of  a  dense  fibrous  connective  tissue,  which  in  all  prob- 
ability are  not  newly  formed,  but  represent  residues  of  the  former 
tissue  of  the  gum  or  the  periosteum. 

VI. — Myeloma. 

We  have  already  given  the  reasons  why  we  prefer  the  term  myeloma 
to  that  of  sarcoma.  These  tumors  are  by  no  means  of  rare  occur- 
rence, as  is  shown  by  the  fact  that  our  comparatively  small  collection 
embraces  five  specimens  of  myeloma  and  its  combinations  out  of 
seventeen  representatives  of  tumors  in  general.  All  these  tumors 
are  considered  malignant  with  one  exception,  which  concerns  the 
variety  termed  "epulis  sarcomatosa, "  or,  as  we  propose  to  call  it, 
fibro-myeloma.  This  variety  is  well  known  to  surgeons  as  admitting 
of  a  radical  cure  if  thoroughly  extirpated.  Multinuclear  bodies  are 
of  such  frequent  occurrence  that  an  authority  like  Virchow  speaks 
of  a  variety  which  he  calls  "giant-cell  sarcoma,"  growing  in  the 
majority  of  cases  from  the  periosteum.  We  have  described,  under  a 
previous  heading,  benign  tumors,   especially  fibroma,   containing  a 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    2,11 

varying  number  of  so-called  giant-cells  in  their  juvenile  portions, 
where  medullary  tissue  prevails,  and  we  have  insisted  that  no  stress 
is  to  be  laid  upon  the  presence  of  "giant-cells."  If  the  tumor  is 
intermixed  with  medullary  tissue  throughout,  the  diagnosis  will  be 
fibro-myeloma,  which  is  still  of  a  low  degree  of  malignity,  as  shown 
by  clinical  experience.  We  can  state  positively  that  the  number  of 
multinuclear  bodies  is  of  great  value  in  determining  the  degree  of 
malignity  in  any  given  case.  The  greater  their  number,  the  surer  it 
is  that  the  tumor  is  not  very  malignant  and  will  not  recur  if  radically 
removed.  On  the  contrary,  the  smaller  their  number  the  greater  is 
the  malignity  and  the  danger  of  recurrence  ;  in  the  worst  cases  of  pure 
globo  or  spindle  myeloma,  multinuclear  bodies  are  lacking  altogether. 
In  such  cases  the  danger  to  the  life  of  the  patient  is  imminent,  in  spite 
of  all  attempts  at  thorough  eradication. 

According  to  our  nomenclature,  we  shall  dwell  upon  combinations 
such  as  myxo,  fibro,  and  osteo-myeloma,  and  finally  consider  the  two 
purely  malignant  forms, — viz,  globo  and  spindle  myeloma.  Any 
of  these  forms  may  arise  primarily  from  the  periosteum  or  medulla 
of  the  jaw-bones,  or  start  in  the  nasal  cavity,  the  antrum  of  High- 
more,  or  the  soft  palate,  and  invade  the  upper  jaw  in  a  secondary 
manner.  In  several  instances  of  primary  myeloma  we  found,  in  the 
tissue  of  the  tumor,  clusters  of  pigment,  indicative  of  a  previous 
hemorrhage,  possibly  in  connection  with  a  traumatism  (blow,  kick, 
fall,  etc.),  which,  as  is  admitted,  often  causes — for  reasons  unknown 
— the  growth  of  malignant  tumors. 

A,  Myxo- Myeloma. — This  specimen  originally  started  on  the  soft 
palate  of  a  young  lady  nearly  twenty  years  of  age,  and  after  extirpa- 
tion recurred  on  the  base  of  the  upper  jaw-bone,  invading  in  turn 
both  the  antrum  and  the  nasal  cavities.  With  low  powers  of  the  micro- 
scope the  tumor  shows  a  thin  investment  of  fibrous  connective  tissue, 
fibers  from  which  penetrate  the  morbid  growth,  scantily  supplied  with 
blood-vessels,  and  producing  imperfect  septa,  by  which  an  indistinct 
alveolar  structure  results.  The  alveoli  are  filled  with  protoplasmic 
bodies,  either  globular  or  spindle-shaped,  or  provided  with  numerous 
offshoots,  by  means  of  which  a  net-like  structure  is  established.  (See 
Fig.  85.) 

Globular  corpuscles  are  arranged  in  clusters,  with  a  scanty  inter- 
vening basis-substance.  Spindle-shaped  corpuscles  are  arranged  in 
tracts,  freely  connecting  at  acute  angles,  and  separated  from  one  an- 
other by  a  slight  amount  of  a  finely-granular  basis-substance.  This 
latter  form  would  correspond  to  that  variety  of  myeloma  termed  by 
Virchow  "net-cell  sarcoma."  The  prevailing  formation  within  the 
alveoli,  however,  corresponds  to  the  illustration,  being  composed  of 
very  large  polymorphous  protoplasmic  masses,  containing,  in  some 


212  DENTAL   PATHOLOGY  AND    PRACTICE. 

parts,  a  number  of  nuclei,,  and  interconnected  by  comparatively  nar- 
row offshoots  in  all  directions.  The  basis-substance  between  these 
formations  is  conspicuous,  and  traversed  by  an  extremely  delicate 
reticulum,  which  arises  from  the  delicate  offshoots  in  a  brush-like 
manner.  This  tissue  is  myxomatous  in  structure,  which,  because  it 
predominates  over  the  structures  before  mentioned,  entitles  the  tumor 
to  the  name  of  myxo-myeloma.     The  myxomatous  tissue  contains 


MVXO-MVELOMA   OF   UPPER  JaW    FILLING   THE    ANTRUM    OF    HiGHMORE. 

F,  tract  of  fibrous  connective  tissue  ;  V,  capillary  blood-vessel  ;  5",  S,  nucleated  protoplas- 
mic tracts  branching  and  finely  interconnecting ;  B,  B,  myxomatous  basis-substance  with  a 
delicate  reticulum  in  connection  with  the  protoplasmic  bodies.     Magnified  600  diameters. 

no  blood-vesSels,  which  are  found  invariably  in  tracts  of  fibrous  con- 
nective tissue,  at  rather  distant  intervals.  As  the  consistence  of  the 
tumor  was  soft,  almost  jelly-like,  the  basis-substance  must  be  of  the 
mucoid  or  myxomatous  variety.  In  cases  where  the  basis-substance 
is  more  firm  the  tumor  has  been  termed  chondro-myeloma,  or  ma- 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    213 

lignant  chondroma,  although  we  would  consider  the  latter  term  as 
illogical. 

B^  Fib ro- Myeloma. — Among  several  tumors  of  this  variety,  we  have 
selected  the  present  specimen  for  description,  its  clinical  history- 
being  better  known.  It  was  located  upon  the  right  side  of  the  lower 
jaw  of  a  man  about  thirty-five  years  of  age,  the  size  of  half  a  hen's 
^^^,  occupying  the  space  between  the  first  bicuspid  and  the  ramus  ; 
the  teeth  in  this  locality  having  previously  been  removed.  Its  con- 
sistence was  firm,  its  surface  slightly  nodular,  its  color  purple,  and 
there  were  nowhere  signs  of  ulceration.  For  a  while  previous  to  its 
removal  it  caused  considerable  pain  of  a  shooting  character.  It  had 
grown  within  about  two  years. 

Under  the  microscope  the  tumor  appears  to  be  composed  of  inter- 
lacing tracts  of  fibrous  connective  tissue,  with  interstices  filled  either 
with  medullary  corpuscles  or  wdth  multinuclear  protoplasmic  bodies  ; 
the  fibrous  portion  being  everywhere  in  excess  over  the  medullary 
tissue.  (Fig.  86. )  The  clusters  of  medullary  corpuscles  are  rather 
numerous,  exhibiting  an  endothelial  appearance.  In  some  places 
blood-vessels  are  seen  to  be  surrounded  with  or  accompanied  by  such 
medullary  corpuscles,  and  in  a  few  places  multinuclear  bodies  are 
visible  in  small  numbers,  but  in  a  remarkably  regular  arrangement. 
The  fact  that  blood-vessels  traverse  the  clusters  excludes  the  conclu- 
sion that  they  are  of  an  epithelial  nature,  and  therefore  the  diagnosis 
of  cancer,  which  could  be  made  upon  a  superficial  glance  at  the  tumor, 
is  untenable.  This  tumor  we  would  not  consider  a  very  malignant 
one,  and  the  diagnosis  of  a  fibroma  would  be  admissible  if  the  med- 
ullary nests  were  not  so  profusely  scattered  throughout  the  tissue. 

A  far  more  malignant  case  of  fibro-myeloma  is  the  following  :  A 
man  about  twenty-five  years  of  age  showed  a  hard  swelling  upon  the 
right  upper  maxilla,  which  had  developed  within  three  years.  The 
tumor  occupied  not  only  the  region  of  the  alveolar  process,  but  also 
the  antrum  of  Highmore.  Most  of  the  teeth  had  become  loose  and 
been  removed,  the  last  two  molars  being  left,  but  very  loose,  and 
nearly  imbedded  in  the  dark-red  mass  of  the  tumor.  The  diagnosis 
was  malignant  tumor,  either  cancer  or  myeloma.  The  whole  right 
maxilla  was  extirpated,  and  a  portion  of  the  alveolar  process  with  a 
tooth  in  it  came  into  our  possession. 

At  the  microscopical  examination  no  trace  of  a  bony  structure 
could  be  found  ;  the  mass  of  the  tumor  consisting  mainly  of  clusters 
of  small  globular  shining  corpuscles,  between  which  an  indistinct 
fibrous  reticulum  was  discernible.  The  clusters  were  separated  from 
one  another  by  bundles  of  fibrous  connective  tissue,  greatly  varying 
in  amount ;  the  surface  of  the  tumor  was  bordered  by  an  indistinct 
capsule  of  the  same  tissue,  which  itself  contained  smaller  clusters  of 


214 


DENTAL    PATHOLOGY    AND    PRACTICE. 


myeloma  corpuscles,  and  showed  irregular,  blunt  elevations  belonging 
to  the  gum,  and  covered  with  a  thin  layer  of  stratified  epithelium. 
In  the  neighborhood  of  the  tooth  the  pericementum  was  still  recog- 

FiG.  86. 


Fibro-Myeloma  with  Multinuclear  Bodies  from  the  Lower  Jaw, 
Z,  Z,,  longitudinal,  7",  transverse  sections  of  bundles  of  fibrous  connective  tissue;  M,M, 
clusters  of  medullary  corpuscles  ;  G,  G,  multinuclear  bodies  or  so-called  giant-cells,  retracted 
from  the  adjacent  connective  tissue  ;   V,  blood-vessel  in  transverse  section  surrounding  a  clus- 
ter of  medullary  corpuscles.     Magnified  6oo  diameters. 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    215 

nizable,  in  the  shape  of  straight  bundles  of  fibrous  connective  tissue, 
remaining  in  connection  with  the  cementum,  but  crowded  with  my- 
eloma corpuscles.     (See  Fig.  87.) 

Fig.  87. 


Fibro-Myeloma  of  the  Upper  Jaw  invading  the  Pericementum. 

C,  cementum  ;  B,  B,  bundles  of  fibrous  connective  tissue  ;  5,  S,  clusters  of  myeloma  cor- 
puscles between  the  bundles  ;  51,  transformation  of  the  bundles  into  the  tissue  of  myeloma, 
with  scanty  traces  of  the  bundles.    Magnified  200  diameters. 


2l6  DENTAL   PATHOLOGY    AND    PRACTICE. 

The  conditions  make  it  evident  that  the  tissue  of  the  myeloma  grew 
at  the  expense  of  the  fibrous  connective  tissue  of  the  pericementum. 
In  some  places  the  bundles  of  the  latter  tissue  are  still  broad,  con- 
taining in  their  middle  slit-like  groups  of  medullary  corpuscles.  In 
other  places  these  corpuscles  have  replaced  the  bundles  to  a  great 
extent  ;  still  deeper,  only  scanty  and  thin  bundles  are  seen  traversing 
the  tissue  of  the  myeloma.  Finally  eler^ents  of  myeloma  occupy 
large  fields,  with  scanty  fibrous  tissue  or  none  at  all  between  them. 
Obviously  the  process  of  transformation  is  explicable  only  if  we  ad- 
mit that  the  whole  of  the  fibrous  connective  tissue,  the  protoplasmic 
bodies  as  well  as  the  basis-substance,  is  supplied  with  living  matter, 
from  which  the  new  formation  of  the  medullary  corpuscles  takes  its 
origin. 

If  we  confine  ourselves  to  the  examination  of  a  limited  portion  of 
this  tumor,  no  differentiation  between  myeloma  and  an  acute  inflam- 
matory process  can  be  made  out,  since  the  medullary  corpuscles 
constituting  myeloma  are  identical  with  inflammatory  corpuscles 
about  ready  to  break  up  into  pus.  It  should  also  be  borne  in  mind 
that  a  rapidly-growing  cancer  may  change  its  character  into  that  of  a 
myeloma,  or  fibro-myeloma,  as  was  first  stated  by  Virchow.  In  speci- 
mens of  such  rapidly-growing  tumors  we  have  always  to  keep  a  sharp 
lookout  for  epithelial  nests,  the  presence  of  which  would  be  evidence 
of  cancer  ;  should  such  nests  be  absent,  we  diagnosticate  myeloma. 
Either  of  these  tumors  involves  considerable  danger  to  the  life  of  the 
patient. 

C,  Osteo- Myeloma. — This  tumor  was  found  in  the  mouth  of  a  lady 
aged  about  thirty,  in  the  region  of  the  bicuspids  upon  the  left  upper 
jaw,  and  had  reached  the  size  of  half  a  robin's  &^^  in  a  year  and  a 
half,  the  teeth  having  previously  been  removed.  The  tumor  exhib- 
ited the  structure  of  a  fibro-myeloma,  invading  principally  the  alveo- 
lar process,  which  .was  reduced  to  minute  remnants  of  bone  scattered 
throughout  the  tissue.     (See  Fig.  88.) 

The  term  osteo-myeloma  is  confined  to  growths  primarily  arising 
in  the  medulla  of  bone,  or  to  growths  holding  newly-formed  bone- 
tissue.  As  the  tumor  in  this  instance  started  in  the  medulla  of  the 
alveolar  process,  and  is  largely  intermixed  with  fibrous  connective 
tissue,  its  proper  title  would  be  osteo-fibro-myeloma.  The  remnants 
of  bone-tissue  give  evidence  of  its  transformation  into  the  mass  of 
the  tumor  through  the  intervening  stage  of  medullary  tissue.  In  a 
few  places  we  find  near  the  border  of  trabeculae  enlarged  lacunae 
containing  several  medullary  corpuscles,  obviously  sprung  from  pre- 
vious bone-corpuscles,  and  still  surrounded  by  a  calcified  basis-sub- 
stance. In  other  places  a  number  of  bone-corpuscles  are  seen  con- 
nected by  means  of  broad  offshoots  into  chains.      In  still  others,  the 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.   21J 

first  step  toward  the  dissolution  of  the  bone-tissue  is  the  appearance 
of  bay-Uke  excavations  corresponding  to  a  previous  territory,  in 
which  protoplasm  makes  its  appearance  ;  or  the  border  of  the  bone 

Fig.  88. 


Osteo-Fibro-Myeloma  of  the  Alveolar  Process  of  the  Upper  Jaw. 

F,  F,  fibrous  connective  tissue  with  numerous  clusters  of  medullary  corpuscles 
clusters  of  pigment-granules  ;  5.  trabeculse  of  bone  indistinctly  lamellated  with  normal 
corpuscles ;  H,  medullary  space  with  central  blood-vessels ;   D,  bay-like  excavation 
bone.    Magnified  200  diameters. 


P,  P, 
bone- 
of  the 


21 8  DENTAL  PATHOLOGY  AND  PRACTICE. 

is  split  up  into  a  number  of  medullary  corpuscles,  which  are  not  yet 
entirely  freed  from  basis-substance.  All  this  is  strong  proof  that  the 
bone  participates  actively  in  the  new  formation  of  the  morbid  tissue, 
the  same  as  it  participates  in  the  process  of  inflammation.  To  say, 
as  some  authors  do,  that  the  bone  is  simply  eaten  up  from  without 
by  the  newly-formed  tissue,  does  not  argue  much  acuteness  of  obser- 
vation ;  since  it  is  by  no  means  difficult  to  satisfy  one's  self  as  to  the 
active  proliferation  of  the  bone-corpuscles  within  the  lacunae.  It  is 
invariably  the  medullary  corpuscles  that  first  appear  from  bone-tissue, 
and  by  subsequent  splitting  into  spindles  and  reinfiltration  with  basis- 
substance  give  rise  to  the  fibrous  portion  of  the  morbid  growth. 

Fig.  89 


Globo-Myeloma  of  the  Periosteum  of  the  Alveolar  Process  of  the  Upper  Jaw. 

B,  delicate  bundles  of  fibrous  connective  tissue  ;  G,  globular  corpuscles  of  myeloma  in  dif- 
ferent stages  of  development.     Magnified  600  diameters. 

D,  Globo-Myeloma. — This  specimen  was  obtained  from  a  tumor 
taken  from  the  mouth  of  a  young  lady  about  twenty  years  of  age. 
It  was  located  on  the  right  upper  jaw,  in  the  region  of  the  bicuspids, 
and  had  grown  to  the  size  of  half  an  English  walnut  in  about  two 
years.  The  teeth  had  previously  been  removed.  It  was  diffusely 
infiltrated  toward  the  neighboring  tissue,  and  evidently  started  from 
the  periosteum.     (See  Fig.  89.) 

The  most  striking  feature  was  the  scarcity  of  fibrous  connective 
tissue,  which  traverses  the  growth  in  delicate  bundles  without  any 
regularity.  The  main  mass  is  composed  of  medullary  corpuscles, 
either  globular  or  polygonal,  the  latter  produced  by  mutual  pressure. 
Between  small  groups  of  such  corpuscles  extremely  delicate  septa  of 
fibrous  tissue  are  visible,  in  which  the  blood-vessels  are  located, 
though  present  only  in  small  numbers. 

Higher  powers  reveal  two  facts  :  first,  that  the  corpuscles  are  inter- 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    219 

connected  by-  delicate  radiating  offshoots,  traversing  the  narrow  spaces 
between  them  ;  second,  that  in  a  limited  field  of  the  tissue  all  stages 
of  development  of  myeloma  can  be  made  out. 

We  see  small  granules  of  a  high  refraction,  structureless,  not  even 
reaching  the  size  of  colorless  blood-corpuscles.  We  see  larger  gran- 
ules and  lumps  with  a  varying  number  of  vacuoles  in  their  interior. 
We  furthermore  see  lumps  with  large,  compact  nuclei,  and  at  last 
corpuscles  with  reticulated  nuclei,  with  granules  in  their  interior, 
and  of  the  ordinary  reticulated  structure  of  protoplasm  Any  gran- 
ule within  the  protoplasm  may  grow  to  the  size  of  a  nucleus,  or  a 
nucleated  corpuscle  ;  the  nuclei  themselves  are  in  an  active  process 
of  division,  as  shown  by  numerous  dumb-bell  forms,  and  figures  of 


Fig.  90. 


Spindle-Mveloma  of  Upper  Jaw. 

L,  L,  longitudinal  sections  of  spindles ;    T,  T,  transverse  sections  of  spindles;   P,  P,  clus- 
ters of  pigment  from  previous  hemorrhage.     Magnified  600  diameters. 

double  or  treble  nuclei  within  a  single  corpuscle.  All  this  is  proof  of 
a  very  rapid  multiplication  of  the  corpuscles,  causing  an  extremely 
rapid  growth  of  the  tumor,  and  indicative  of  a  high  degree  of  malig- 
nancy. In  accord  with  the  latter  features,  not  a  single  multinuclear 
body  or  ' '  giant-cell' '  can  be  seen,  not  even  where  somewhat  broader 
bundles  of  fibrous  tissue,  pr6bably  belonging  to  the  periosteum,  are 
present. 

E,  Spindle  Myeloma. — This  tumor,  corresponding  to  what  Virchow 
has  termed  "  spindle- cell  sarcoma,"  is  represented  in  our  collection 
by  a  specimen  the  history  of  which  is  unknown  to  us.  All  we  can 
say  is  that  it  had  grown  in  the  upper  jaw.     (See  Fig.  90.) 

The  tumor  is  largely  composed  of  spindles,   but  in  some  places 


220  DENTAL    PATHOLOGY   AND    PRACTICE. 

globular  corpuscles  are  seen,  a  feature  which  would  entitle  the  tumor 
to  the  name  of  a  combined  globo-and-spindle  myeloma.  The  tumor 
has  comparatively  little  of  fibrous  connective  tissue,  and  in  this  scanty 
blood-vessels  are  seen.  The  spindles  are  arranged  in  interlacing 
groups  ;  in  almost  every  field  we  meet  with  longitudinal  and  trans- 
verse sections  of  spindles,  all  of  which  are  interconnected  by  delicate 
offshoots.  The  rapid  growth  of  the  tumor  is  indicated  mainly  by 
coarsely-granular  nuclei,  or  chains  of  coarse  granules  replacing  the 
nuclei.  In  some  places  clusters  of  red-brown  pigment-granules  are 
seen,  but  in  such  small  numbers  that  the  tumor  cannot  be  properly 
called  pigmented  or  melanotic  myeloma.  The  pigment  appears  either 
in  spindle-shaped  or  irregular  clusters,  partly  within  and  partly  be- 
tween the  spindle-shaped  corpuscles.  These  pigment-clusters  are 
unquestionably  the  result  of  a  previous  hemorrhage,  possibly  caused 
by  a  mechanical  injury,  giving  issue  to  the  myelomatous  new  growth. 

VII. — Carcinoma. 

This  type  of  tumors  is  characterized  by  the  presence  ot  epithelial 
nests,  scattered  without  regularity  in  the  connective  tissue,  which 
may  be  either  myxomatous  or  fibrous.  Most  pathologists  claim  that 
cancer  may  originate  only  in  such  tissues  as  are  covered  with  or  con- 
tain normal  epithelia.  The  mucosa  of  both  the  oral  and  nasal  cav- 
ities is  the  starting-point  of  cancerous  growths,  and  in  the  upper 
jaw  there  is  an  additional  source  in  the  mucosa  of  the  antrum.  Again, 
the  cancer  may  be  primary  in  the  tissue  just  named,  or  secondary  by 
invasion  from  the  skin  or  from  any  glandular  formation, — for  instance, 
from  the  salivary  glands. 

There  are  three  varieties  of  cancer  recognized  by  modern  patholo- 
gists :  first,  scirrhous,  with  comparatively  small  nests  of  epithelia, 
and  a  large  amount  of  fibrous  connective  tissue  around  the  nests  ; 
second,  epithelioma,  with  concentrically  arranged  flat  epithelia  fill- 
ing the  nests,  and  a  varying  amount  of  fibrous  tissue  between  them  ; 
and,  third,  medullary  cancer,  with  small  and  irregular  epithelia  in 
the  nests,  and  a  scanty  fibrous  tissue  between  them.  Of  these  three 
varieties  our  collection  contains  examples  of  two,  epithelioma  and 
medullary  cancer,  both  having  reached  the  upper  jaw  from  adjacent 
epithelial  structures,  skin  and  mucous  membrane. 

A,  Epithelioina. — We  have  two  cases  of  this  type  of  cancer,  both 
from  men  over  forty  years  of  age.  In  one  the  tumor  arose  in  the 
mucosa  of  the  antrum,  and  in  the  other  in  that  of  the  floor  of  the 
nasal  cavity,  both  being  similar  in  structure.     (See  Fig.  91.) 

In  examining  the  specimen  of  epithelioma  from  the  mucosa  of  the 
antrum,  we  observe  marked  differences  in  the  structure  of  the  epithe- 
lia.    Near  the  boundary  toward  the  connective  tissue  they  are  smaller 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    221 

and  narrower  than  in  the  middle  portions  of  the  nests.  They  are 
often  replaced  by  a  row  of  medullary  corpuscles,  to  such  an  extent 
that  no  sharp  boundary  line  exists  between  the  connective  tissue  and 

Fig.  91. 


Epithelioma  of  the  Mucosa  of  the  Antrum. 
C,   delicate  fibrous  connective  tissue  crowded  with  medullary  corpuscles;    y,  capillary 
blood-vessels  in   the   connective  tissue;    £,   E,    epithelial   nests   made   up   of  concentrically 
arranged  flat  epithelia  ;    P,  P,  cancer-pearls  composed  of  changed  epithelia.     Magnified  200 
diameters. 


222  DENTAL    PATHOLOGY    AND    PRACTICE. 

the  epithelial  nest.  Obviously  this  means  a  gradual  transformation 
of  the  medullary  into  epithelial  tissue,  a  process  which  leads  to  the 
increase  of  the  bulk  of  the  nests  and  a  decrease  of  that  of  the  con- 
nective tissue.  Finally,  even  the  blood-vessels  being  obliterated,  the 
nests  are  deprived  of  nourishing  material,  and  a  local  necrosis — viz, 
ulceration — takes  place,  which  is  a  common  feature  in  all  cancers. 

The  second  prominent  feature  is  an  active  new  formation  of  living 
matter  in  the  epithelia.  This  causes  the  nuclei  to  become  homo- 
geneous ;  then  to  assume  an  hour-glass  shape,  and  lastly  to  divide 
into  several  nuclei.  Not  infrequently  we  see  several  nuclei  or  several 
medullary  corpuscles  within  a  considerably  enlarged  epithelium. 
Such  formations  have  been  termed  ' '  mother  cells' '  by  previous  path- 
ologists, but  we  now  know  that  they  are  the  outcome  of  an  active 
endogenous  new  formation.  Around  the  nucleus  often  are  seen 
vacuoles,  or  plasmatic  spaces,  which  evidently  contain  nourishing 
liquid,  enabling  the  nucleus  to  rapidly  increase  its  proportion  of  living 
matter,  with  the  result  of  fission  and  division,  and  a  rapid  new  forma- 
tion of  epithelia.  Except  where  the  nucleus  is  surrounded  by  a 
vacuole,  it  is  in  connection  with  the  adjacent  protoplasm  of  the  epi- 
thelium, by  means  of  delicate  conical  oifshoots.  Similar  offshoots  also 
traverse  the  cement-substance  between  the  epithelia,  thus  uniting  all 
into  a  continuous  mass  of  protoplasm  The  central  portions  of  the 
nests  often  contain  groups  of  epithelia,  which  have  assumed  a  high 
degree  of  refraction,  a  yellowish  color,  and  a  homogeneous  appear- 
ance. At  first  the  nuclei  remain,  though  only  faintly  discernible  ; 
but  in  the  more  advanced  degrees  of  this  metamorphosis  even  the 
traces  of  nuclei  are  lost,  and  a  certain  number  of  epithelia  are  trans- 
formed into  structureless  glistening  plugs,  representing  the  well- 
known  cancer-pearls.     The  nature  of  this  process  is  not  yet  known. 

The  connective  tissue  is  of  either  the  myxomatous  or  the  fibrous 
variety  ;  never  very  rich  in  blood-vessels,  which  are  mostly  capillaries 
and  veins.  In  many  places  the  connective  tissue  is  crowded  with 
medullary  or  lymph- corpuscles,  between  which  a  delicate  reticulum 
is  seen.  Some  authors  regard  this  as  the  result  of  an  inflammatory 
reaction  of  the  epithelial  upon  the  connective  tissue,  but  we  claim 
that  it  is  the  medullary  condition  of  the  connective  tissue  from  which 
new  epithelia  arise.  We  base  our  views  upon  direct  observation, 
since  we  know  that  if,  after  removal  of  cancer-nests,  lymph-corpus- 
cles be  left  behind,  even  though  at  a  great  distance  from  the  cancer 
itself,  the  disease  will  invariably  recur.  This  fact  urges  upon  us  the 
necessity  for  removal  of  large  portions  of  tissue  in  the  neighborhood 
of  cancer.  Modern  surgeons,  by  clinical  experience,  have  reached 
the  same  conclusion,  considering  the  course  indicated  the  only  safe- 
guard against  relapses,  which  are  so  very  common  in  this  disease. 


CONTRIBUTIONS  TO  THE  KNOWLEDGE  OF  TUMORS  OF  THE  JAWS.    223 

Unfortunately,  we  are  not  able  to  say  why  the  lymph-corpuscles  or 
the  medullary  tissue,  into  which  the  connective  tissue  is  transformed 
in  an  almost  identical  way  with  inflammatory  infiltration,  should  have 
such  a  marked  capacity  for  changing  into  epithelia  ;  in  other  words, 
wherein  the  contagion  of  the  tissue  lies. 

B,  Medullary  Cancer. — Our  specimen  is  taken  from  the  enor- 
mously enlarged  alveolar  process  of  the  upper  jaw  of  a  man  over  sixty 
years  of  age.  Twelve  years  previous  to  his  death  he  was  first  oper- 
ated upon  for  a  so-called  rodent  ulcer,  upon  the  left  wing  of  the  nose, 
which  about  fifteen  years  previously  had  originated  from  a  slight 
injury,  causing  a  shallow  ulcer,  which  could  never  be  induced  to  heal. 
The  scooped-out  particles  of  tissue  from  the  first  operation  were  ex- 
amined under  the  microscope,  and  showed  the  structure  of  a  shallow 
or  flat  epithelioma,  which  previous  authors  termed  "rodent  ulcer." 

Repeated  recurrences  and  operations  took  place  afterward,  until 
the  left  upper  jaw  began  to  swell,  the  left  eye  was  pushed  up  and 
forward,  and  the  teeth  became  so  loose  and  troublesome  that  they  had 
to  be  removed.  The  swelling  of  the  face  proved  to  be  greatly  aug- 
mented by  an  apparently  long-standing  abscess  in  the  antrum,  the 
result  of  the  death  of  a  second  molar  many  years  before,  the  roots  of 
which  penetrated  its  floor.  Upon  the  removal  of  this  tooth  a  large 
quantity  of  fetid  pus  escaped,  and  a  temporary  improvement  was  the 
result.  Later  the  swelling  invaded  the  front  of  the  mouth  and 
passed  to  the  right  side  to  such  a  degree  that  several  operations  were 
required  to  remove  the  fungoid,  easily-bleeding  masses  of  the  alve- 
olar process,  gum,  and  hard  palate,  which  were  almost  choking  the 
patient.  The  purpose  of  these  operations  was  not  to  remove  the 
cancer,  but  to  prevent  death  from  suffocation  or  starvation.  This 
specimen  is  a  type  of  medullary  cancer.     (See  Fig.  92.) 

The  specimen  exhibited  in  some  places  an  almost  unchanged 
stratified  epithelium  covering  the  papillae  of  the  gum.  In  other 
places  the  papillae  are  much  enlarged  and  flattened.  Still  further, 
the  papillae  have  entirely  disappeared  and  the  epithelial  layer  is  con- 
siderably thinned,  until  at  last  the  epithelium  has  disappeared,  and 
an  ulcerating  cancer-tissue  appeared  upon  the  surface.  In  those 
places  where  the  epithelial  stratum  of  the  gum  appears  thinned  the 
deepest  or  columnar  row  of  epithelia  as  well  as  the  lower  layers  of 
cuboidal  epithelia  are  absent,  and  are  replaced  by  a  medullary  tissue 
of  a  myxomatous  character,  which  has  incidentally  sprung  from  the 
previous  epithelia.  We  feel  the  more  confident  of  such  change  having 
taken  place  from  the  fact  that  at  the  border  between  the  epithelial 
and  medullary  tissues  the  epithelial  bodies  themselves  show  a  marked 
increase  of  living  matter,  and  a  gradual  transformation  into  medul- 
lary corpuscles. 


224 


DENTAL    PATHOLOGY   AND    PRACTICE. 


Close  beneath  the  medullary  layer  nests  of  epithelia  make  their 
appearance,  separated  from  one  another  by,  first,  medullary,  and 
deeper  in  by  a  delicate  fibrous  connective  tissue,  which  latter  has 
evidently  originated  from  the  former.  We  therefore  maintain  that  a 
medullary  tissue  arising  from  previous  normal  epithelia  may  change 
into  fibrous  connective  tissue,  and  vice  versa,  that  medullary  tissue 

Fig.  92. 


Medullary     Cancer    of    thk    Left   Upper    Jaw,    Invading    the    Alveolar     Process 

AND  Gum. 

N,  N,  nests  of  irregular  polyhedral  epithelia ;    C,  C,  delicate  fibrous  connective  tissue  be- 
tween the  nests ;    V,  vein.     Magnified  600  diameters. 

which  arose  from  connective  tissue  may  eventually  be  converted  into 
the  epithelia  of  cancer. 

The  medullary  nests  are  made  up  of  very  irregular  bodies,  which 
by  pressure  have  assumed  a  polygonal  form.  In  many  instances  a 
whole  nest  or  a  portion  of  it  is  made  up  of  granular  protoplasm,  with 


SENILE    ATROPHY    OF    THE    UPPER   JAW.  225 

nuclei  scattered  at  regular  intervals,  without  any  intervening  cement- 
substance.  Where  the  latter  is  present  in  the  shape  of  a  narrow 
ledge,  it  is  invariably  pierced  by  delicate  offshoots  or  thorns,  inter- 
connecting the  single  epithelial  elements.  The  changes  of  the  epi- 
thelia  toward  proliferation  are  much  the  same  as  in  the  epithelioma 
before  described.  The  connective  tissue  shows  a  transformation  into 
lymph- tissue  to  a  great  extent.  Where  it  has  retained  its  fibrous  char- 
acter it  is  scanty,  separating  the  epithelial  nests  and  carrying  a  large 
number  of  protoplasmic  bodies.  The  blood-vessels  running  therein 
are  scanty,  and  are  mostly  capillaries  and  veins.  The  latter  often 
show  sinuous  contours,  and  are  replete  with  blood-corpuscles. 

As  stated  in  the  discussion  of  epithelioma,  the  secret  of  the  general 
and  local  contagiousness  of  cancer  has  never  been  unveiled,  but  still 
awaits  the  future  discoverer. 


CHAPTER    XXII. 

SENILE  ATROPHY  OF  THE  UPPER  JAW.« 

With  advancing  age  the  human  organism  is  reduced  in  size  and 
weight ;  the  more  so,  as  a  rule,  after  the  "  threescore  years  and  ten" 
have  passed.  The  whole  body  shrinks,  as  well  as  all  its  individual 
tissues.  Age  itself  is  disease.  The  old  Roman  proverb  says,  "And 
the  aged  returns  to  childhood,  both  mentally  and  physically."  The 
questions  which  we'have  tried  to  solve  are.  In  what  does  this  atrophy 
take  place  ?     What  are  its  visible  signs  under  the  microscope  ? 

Through  the  kindness  of  Dr.  Emmons  Paine,  superintendent  of 
the  insane  hospital  in  Westborough,  Mass.,  we  came  into  possession 
of  the  upper  jaw  of  a  woman,  who  died  at  the  age  of  seventy-five 
years.  The  jaw,  immediately  after  removal,  was  placed  in  a  one-half 
of  one  per  cent,  solution  of  chromic  acid,  in  which  it  remained  for 
several  weeks  for  the  purpose  of  softening  the  bony  parts.  We  lay 
stress  upon  this  fact,  because  previous  researches  upon  senile  bone 
have  been  made  upon  dried  specimens,  by  which  method  we  are  con- 
vinced that  the  results  of  microscopical  research  must  have  been 
marred,  if  not  rendered  futile.  The  entire  thickness  of  this  jaw,  from 
the  oral  to  the  nasal  surface,  was  not  more  than  from  four  to  five  mil- 
limeters ;  the  oral  surface  was  perfectly  smooth,  without  a  trace  of  a 
tooth  or  a  socket.  A  slight  indication  of  the  central  raphe  could  be 
seen.  Vertical  sections  through  it  give  striking  pictures  of  far-ad- 
vanced senile  atrophy.     (See  Fig.  93.) 

*Heitzmann  and  Abbott,  Dental  Cosmos,  1892. 
16 


226 


DENTAL    PATHOLOGY    AND    PRACTICE. 


The  stratified  epithelium  of  the  oral  mucosa  terminates  in  an  almost 
even  line  without  the  least  indications  of  former  gums,  the  body 
of  the  epithelium  being  considerably  narrowed.  The  papillae,  so 
prominent  in  the  region  of  the  gums  in  a  normal  condition,  are  still 

Fig.  93. 


Atrophied  Upper  Jaw.    Vertical  Section. 

£,  stratified  epithelia  of  mucosa  of  oral  cavity;  Z,  longitudinal  bundles  of  fibrous  connective 
tissue  ;  T,  transverse  bundles  of  fibrous  connective  tissue  ;  5,  spaces  in  connective  tissue ;  F, 
fat-globules;  C,  hyaline  cartilage ;  ^,  artery,  probably  in  a  previous  alveolar  canal;  ^.cancel- 
lous bone ;  71/,  medullary  space.    Magnified  50  diameters. 

present,  but  considerably  shortened  and  narrowed.  The  fibrous  con- 
nective tissue  is  markedly  reduced  in  its  total  quantity,  as  well  as  in 
the  width  of  its  bundles,  as  seen  best  in  their  transverse  section.     The 


SENILE   ATROPHY    OF   THE   UPPER   JAW.  •  227 

connective  tissue,  including  that  of  the  former  gums  and  that  of  the 
periosteum,  runs  an  almost  horizontal  course,  interlaced  nearly  rec- 
tangularly by  bundles  and  tracts  of  the  same  tissue.  It  is  traversed 
by  numerous  fissures,  or  slits,  which  were  probably  caused  by  me- 
chanical injury  in  the  process  of  cutting.  This  feature  in  otherwise 
perfect  sections  would  indicate  that  the  connection  of  the  bundles  is  an 
extremely  delicate  one.  Fat-tissue,  so  abundant  in  both  the  periosteal 
connective  tissue  and  the  medullary  spaces  of  the  cancellous  bone  of 
the  jaws  of  the  young  and  middle-aged,  is  extremely  scanty.  The 
bone  itself  produces  only  thin  ledges  bordered  by  an  irregularly  cor- 
roded line,  without  a  distinction  between  compact  and  cancellous 
structure.  The  medullary  spaces  vary  greatly  in  size,  and  are  filled 
either  with  a  delicate  fibrous  connective  tissue,  or  with  granular  matter, 
probably  disintegrated  protoplasm.  The  most  striking  feature  is  the 
presence  of  portions  of  hyaline  cartilage,  of  the  same  height  as  the 
bony  tissues  left,  which  goes  far  to  prove  that  the  cartilage  has  grown 
from  a  former  bony  structure,  and  has  in  a  measure  replaced  it.  As 
is  well  known,  hyaline  cartilage  is  present  in  the  lower  jaw  only  at 
the  earliest  stages  of  embryonal  life,  up  to  the  eighth  week  of  devel- 
opment. Around  and  from  this  so-called  primordial  cartilage  bone- 
tissue  develops,  and  in  the  third  month  of  intra-uterine  life  all  vestige 
of  cartilage  is  lost.  How  much  hyaline  cartilage  has  to  do  with  the 
development  of  the  upper  jaw,  we  are  unable  to  tell.  Most  anato- 
mists consider  the  upper  jaw  as  having  sprung  from  fibrous  connective 
tissue,  in  a  way  similar  to  that  of  all  flat  facial  and  skull  bones. 
However  this  may  be,  it  is  certainly  remarkable  that  hyaline  cartilage 
should  reappear  in  the  upper  jaw  of  the  aged,  proving,  as  it  were, 
that  advanced  age  is  a  recurrence  to  childhood,  even  to  intra-uterine 
life. 

Let  us  now  consider  the  senile  changes  of  the  tissues  involved  in 
the  formation  of  the  upper  jaw. 

I.  Epithelium. — As  mentioned  before,  the  layer  of  stratified  epithe- 
lium has  been  considerably  reduced  in  bulk,  although  its  three  con- 
stituent portions  are  still  recognizable,  the  main  mass  being  made  up 
of  cuboidal  epithelia,  while  the  outermost  or  horny  layer  is  com- 
posed of  several  rows  of  flat  epithelia,  and  the  border  toward  the 
connective  tissue  is  established  by  a  single  row  of  columnar  epithe- 
lium.    (See  Fig.  94.) 

Horizontal  sections  through  the  mucosa  show  the  thinning  of  the 
epithelial  layer  even  better  than  vertical  ones  ;  in  the  former,  also,  the 
row  of  columnar  epithelia  is  better  marked  than  in  vertical  sections. 
Most  of  the  epithelia  are  much  less  conspicuous  than  in  childhood  or 
middle  age.  This  may  be  accounted  for,  first,  by  the  fine  granula- 
tion of  both  the  protoplasm  and  the  nuclei  ;  second,  by  a  reduction 


228 


DENTAL    PATHOLOGY    AND    PRACTICE. 


in  the  amount  of  the  intervening  cement-substance  ;  and  third,  by 
a  noticeable  reduction  of  the  bulk  of  each  epithelium.  An  additional 
feature  is  that  many  of  the  original  epithelia  seem  to  have  split  up 
into  smaller  lumps.  In  many  instances,  only  faintly-outlined  nuclei 
are  to  be  seen,  so  closely  packed  together  that  but  little  intervening 
protoplasm  is  discernible. 

Fig.  94, 


Oral  Epithelium  of  Senile  Upper  Jaw.    Vertical  Section. 

i^  layer  of  flat  epithelia;  Ci,  cuboidal  epithelia  with  solid  nuclei';  C^,  cuboidal  epithelia  of 
small  size,  with  small  vesicular  nuclei;  M,  multinuclear  layers  of  protoplasm;  Co,  columnar 
epithelium;  V,  F,  capillary  blood-vessels  traversing  the  middle  epithelial  layer;  O,  O,  myxo- 
fibrous  connective  tissue  of  oral  mucosa.    Magnified  600  diameters. 

In  many  cases  cement-substance  is  lacking  altogether,  to  such  an 
extent  that  the  impression  of  multinuclear  bodies  is  produced  ;  wher- 
ever cement-substance  is  present,  though  its  ledges  be  ever  so  narrow, 
the  delicate  thorns  traversing  it  are  invariably  traceable. 

In  some  places,  however,  the  nuclei  of  the  cuboidal  epithelia  are 


SENILE   ATROPHY    OF   THE   UPPER   JAW.  229 

almost  solid  glistening  lumps,  such  as  we  are  accustomed  to  see  in 
either  a  juvenile  or  an  inflamed  condition  of  epithelium. 

Broader  epithelial  valleys  show  in  vertical  sections  narrow  crevices, 
each  holding  a  minute  capillary  blood-vessel.  This  may  be  explained 
by  the  shrinkage  of  previous  papilla  ;  though  this  view  is  hardly  tena- 
ble in  the  face  of  the  fact  that  all  well-pronounced  papillae  are  supplied 
with  a  small  number  of  blood-vessels.  The  view  is  more  probable 
that  capillaries  with  a  little  accompanying  connective  tissue  have 
grown  into  the  epithelial  layer  from  without,  thus  causing,  or  at  least 
assisting  in,  the  atrophy  of  the  epithelium. 

This  much  is  certain,  that  the  reduction  of  the  sum-total  of  the 
covering  epithelium  is  caused  mainly  by  a  reduction  in  the  size  of 
each  epithelial  body.  We  are,  however,  unable  to  say  where  the  lost 
material  has  gone,  unless  it  was  absorbed  by  newly-formed  capillaries 
grown  into  the  epithelial  layer.  A  transformation  of  the  epithelia, 
first  into  medullary  corpuscles,  and  afterward  into  connective  tissue, 
a  process  so  common  in  inflammation  and  the  formation  of  tumors, 
could  nowhere  be  satisfactorily  proven  in  our  specimens,  and  seems  to 
be  little  probable,  since,  as  stated  above,  the  columnar  epithelia  appear 
unbroken  ;  possibly  mastication  has  been  more  or  less  instrumental 
in  removing  layer  after  layer  of  epithelia. 

2.  Fibrous  Connective  Tissue. — The  senile  changes  of  the  oral 
mucosa  are  explicable  only  upon  the  fact,  established  by  Heitzmann 
in  1873,  that  the  protoplasmic  bodies  lie  between  the  bundles  of  the 
fibrous  connective  tissue,  and  that  the  bundles  themselves  are  not  alto- 
gether inert  glue-yielding  basis-substance,  but  are  traversed  by  an 
extremely  delicate,  almost  rectangular,  net-work  of  living  matter. 
The  bundles,  therefore,  as  well  as  the  protoplasm  itself,  are  possessed 
of  life. 

Close  around  the  epithelia,  and  in  the  remnants  of  the  papillae,  we 
notice  delicate  bundles  holding  a  large  number  of  finely  granular 
bodies,  and  but  a  small  number  of  capillary  blood-vessels. 

This  tissue  certainly  differs  from  what  we  are  accustomed  to  see  in 
youth  and  in  middle  age.  It  may  be  termed  myxo-fibrous  connective 
tissue,  such  as  is  seen  in  tumors  of  the  skin  and  mucous  layers, 
termed  myxo-fibromata.  This  tissue  exhibits  the  same  aspect,  both 
in  vertical  and  horizontal  sections  of  the  senile  jaw.  (See  Fig.  94, 
C>,  C  ) 

The  fibrous  tissue  proper  is,  as  mentioned  above,  noticeable  by  the 
small  size  of  its  constituent  bundles,  as  shown  both  in  their  longitu- 
dinal and  transverse  sections.  The  changes  of  this  tissue  and  its 
tenants,  which  are  obviously  the  result  of  advanced  age,  are  really 
surprising.     (See  Fig.  95.) 

The  bundles  quite  frequently  show,   under  lower  powers  of  the 


230 


DENTAL   PATHOLOGY   AND    PRACTICE. 


microscope,  a  faint  granulation,  which,  if  viewed  with  high  powers, 
proves  to  be  the  reticulum  of  living  matter  already  alluded  to.  This 
goes  to  show  that  the  tissues,  especially  their  matrices,  or  basis-sub- 
stance, remain  alive  to  the  last.  Some  of  the  longitudinal  bundles 
appear  split  up  into  faintly-marked  medullary  corpuscles,  visible 
especially  in  longitudinal  sections.     (Fig.  95,  M.)     Here,  evidently,  a 

Fjg.  95. 


Oral  Mucosa  of  Senile  Upper  Jaw.    Horizontal  Section. 

Z,,  longitudinal  bundles  of  fibrous  connective  tissue ;  T,  transverse  bundles  of  fibrous  con- 
nective tissue;  TV,  TV,  medullated  nerve-fiber;  A,  artery;  C,  capillary  blood-vessel  partly  nar- 
rowed, partly  obliterated ;  M,  bundle  of  fibrous  connective  tissue  split  up  into  medullary 
corpuscles;  /,  cluster  of  indifferent  corpuscles  ;  £■,  elastic  fiber  ;  /*,  finely  granular  protoplasm. 
Magnified  600  diameters. 

slight  liquefaction  of  the  glue-yielding  basis-substance  has  occurred, 
leading,  as  it  were,  to  a  rejuvenescence  of  the  bundle,  i.e.,  a  reappear- 
ance of  those  embryonal  corpuscles  which  in  the  earliest  stage  of 
development  have  built  up  the  bundle.     In  other  places  clusters  of 
glistening  homogeneous  globules  make  their  appearance,   scattered 


SENILE   ATROPHY    OF   THE   UPPER   JAW.  23I 

through  a  finely-granular  protoplasm.  These  globules  are  even  smaller 
in  size  than  the  medullary  corpuscles  from  which  ameloblasts  originate. 
(Fig.  95,  /)  Nests  of  this  description  are  similar  to  those  seen  in 
inflammation  of  the  fibrous  connective  tissue,  but  we  conclude  that 
the  nests  seen  in  our  specimens,  owing  to  their  diminutive  size  and 
scantiness,  are  not  inflammatory.  There  is  no  doubt  in  our  minds 
that,  exactly  as  in  the  process  of  inflammation,  a  recurrence  of  the 
juvenile  or  medullary  condition  has  taken  place.  There  is  no  doubt 
either  that  a  liquefaction  of  the  basis-substance  has  taken  place  in 
these  nests,  leading  first  to  a  reappearance  of  protoplasm,  and  after- 
ward to  an  increase  of  the  living  matter  thereof,  up  to  the  formation 
of  the  glistening  lumps  under  consideration.  The  nests  are  still 
traversed  by  faint  vestiges  of  the  former  bundles,  the  same  as  we  ob- 
serve in  early  stages  of  inflammation. 

The  thinning  of  the  bundles  is  unquestionably  caused  by  their 
gradual  transformation  into  protoplasm,  since  the  interstices  are 
found,  in  many  instances,  widened  and  filled  with  protoplasm  of  a 
finely  granular  character,  which  means  a  small  amount  of  living 
matter.  The  ultimate  fate  of  the  bundles  is,  that  the  basis-substance 
is  liquefied,  and  nothing  is  left  but  the  framework  of  elastic  fibers 
which  have  previously  bordered  the  bundles,  and  which,  on  account 
of  their  chemical  composition,  are  less  destructible  than  ordinary 
glue-yielding  basis-substance.     (Fig.  95,  E.) 

The  result  is  that  where  formerly  dense  fibrous  connective  tissue 
was  present  a  faintly  granular  protoplasmic  mass  is  now  seen,  the 
living  matter  of  which  is  scanty  and  pale,  apparently  on  account  of  a 
hydropic  infiltration  of  the  same.  This  will  explain  the  flabbiness  of 
the  tissues  of  the  aged  on  the  one  hand,  and  the  gradual  loss  of  living 
matter  on  the  other.  For  we  realize  that  particles  of  living  matter 
with  serum  imbibed  will  be  gradually  detached  from  the  mother  soil, 
disintegrated,  and  taken  back  into  the  circulation  through  the  scanty 
blood-  and  lymph-vessels  left.  The  general  shrinkage  of  the  body 
thus  becomes  intelligible. 

3.  Blood-  Vessels. — The  fibrous  connective  tissue  of  the  oral  mucosa 
is.  as  is  well  known,  freely  supplied  with  blood-vessels — arteries, 
capillaries,  and  veins — during  the  ascending  period  of  life,  while  it 
holds  surprisingly  few  vessels  in  advanced  age.  In  our  specimens  we 
have  a  good  opportunity  to  trace  the  manner  in  which  the  blood- 
vessels perish.  Smaller  arteries  show  in  their  muscular  walls  an 
augmentation  of  the  nuclei  to  such  an  extent  that  the  spindles  of  the 
smooth  muscle-fibers  become  replaced  by  rows  of  minute  glistening 
globules.  (Fig  95,  A.)  An  artery  may  thus  become  so  changed  in 
its  aspect  that  it  were  impossible  to  tell  its  original  character,  except 
through  its  attachment  to  a  less  altered  artery  of  which  it  forms  a 


232  DENTAL   PATHOLOGY   AND    PRACTICE. 

branch.  The  endothelium  of  the  inner  coat  Hkewise  is  thickened  and  . 
more  or  less  crowded  with  coarse  granules  of  living  matter,  by  which 
means  the  lumen  becomes  at  first  narrowed  and  ultimately  choked. 
The  fibrous  connective  tissue  of  the  adventitial  coat  behaves  in  a  way 
similar  to  that  of  the  mucosa  generally,  i.e.,  it  is  gradually  reduced  to 
its  juvenile  or  embryonal  condition.  After  an  artery  has  thus  become 
impermeable  to  the  current  of  the  blood,  it  is  in  turn  transformed  into 
a  solid  tract  of  fibrous  connective  tissue,  and  as  such  is  subject  to  the 
changes  above  described.  The  capillaries  being  composed  of  a  single 
endothelial  wall  only,  are  easily  traceable  in  their  course  to  final  oblit- 
eration. The  endothelia  swell  up,  become  coarsely  granular,  and,  by 
their  bulging,  the  caliber  of  the  capillary  is  narrowed  and  rendered  star- 
shaped.  The  augmentation  of  the  living  matter  proceeds  up  to  a  com- 
plete occlusion  of  its  walls,  such  as  is  often  seen  in  the  process  of 
inflammation.  The  result  is  a  solid  cluster  of  protoplasm  in  place  of 
the  previously  hollow  vessel.  It  seems  that  the  nests  of  the  glistening 
globules  above  alluded  to  are  more  numerous  in  the  neighborhood  of 
blood-vessels,  or  in  places  where  blood-vessels  had  previously  been. 
(Fig.  95,  C)  Those  who  favor  the-  emigration  theory  in  inflammation 
must  be  at  a  loss  to  explain  the  appearance  of  indifferent  or  inflamma- 
tory corpuscles  in  places  where  the  blood-vessels  have  perished.  With 
us  who  urge  the  origin  of  such  corpuscles  from  the  protoplasm — from 
both  its  living  matter  and  the  living  matter  of  the  basis-substance — the 
images  furnished  by  the  microscope  are  explicable  without  any  diffi- 
culty. That  veins  are  gradually  being  obliterated  in  a  way  similar  to 
that  of  arteries  and  capillaries  is  almost  a  matter  of  course,  although 
we  have  not  been  able  to  trace  this  process  directly  in  our  speci- 
mens. 

4.  Nerves. — Here  and  there  we  meet  with  medullated  nerves,  recog- 
nizable as  such  by  their  course  and  their  connection  with  other  little 
or  entirely  unchanged  nerves,  which  exhibit  striking  changes.  Such 
changes  are  usually  met  with  in  the  process  of  neuritis  ;  but  in  this 
instance,  neuritis  not  being  present,  they  must  be  attributed  to  senile 
changes.  There  is  nothing  surprising  in  the  similarity  between  in- 
flammation and  senile  metamorphosis,  since  both  are  essentially  a  re- 
turn to  the  juvenile  or  medullary  condition.  Some  medullated  nerves 
appear  to  be  broken  up  into  glossy  lumps,  owing  to  a  splitting  up  of 
the  myelin  ;  at  the  same  time  the  parallelism  of  the  contours  is  lost, 
and  the  nerves  show  spindle-shaped  widenings,  alternating  with  narrow 
tracts.  (Fig.  95,  N,  N.)  The  shining  lumps  at  least  are  probably 
transformed  into  protoplasmic  or  medullary  bodies,  which  in  turn  are 
transformed  into  spindles,  and  ultimately  into  fibrous  connective 
tissue.  Thus  both  the  constrictions  in  the  course  of  the  nerve  and 
the  augmentation  of  the  perineurium  become  intelligible,  as  well   as 


SENILE    ATROPHY    OF   THE    UPPER    JAW. 


233 


the  final  loss  of  nerves,  through  their  transformation  into  fibrous 
connective  tissue.  As  to  the  changes  of  the  axis-cylinders,  we  can 
say  nothing,  since  meduUated  nerves  are  unsuitable  for  the  study  of 
this  particular  portion. 

5.  Cartilage. — The  appearance  of  hyaline  cartilage  (Fig.  96)  in  a 
senile  jaw  is,  as  we  have  before  remarked,  a  most  surjn'ising  fact, 
going  far  to  prove  that  rejuvenescence  of  the  tissues  takes  place  in  old 
age.     Hyaline  cartilage  is  no  doubt  a  transient  or  provisional  tissue  in 

Fig.  96. 


Cartilage  from  Senile  Jaw. 

M,  medullary  corpuscles ;  Z.,  small  lumps  of  living  matter;  B,  cartilage-corpuscles  trans- 
formed into  basis-substance  ;  G,  cartilage-corpuscles,  partly  coarsely  and  partly  finely  granular. 
Magnified  800  diameters. 

early  embryonal  life,  and  the  same  seems  to  be  the  case  in  declining 
age,  since  it  appears  as  a  mere  intermediate  tissue  between  previous 
bone  and  the  ultimate  tissue,  i.e.,  fibrous  connective  tissue. 

Hyaline  cartilage  in  this  case  appears  as  a  thin  rounded-off  plate, 
characterized  by  small  and  flat  cartilage-corpuscles  along  the  borders, 
while  the  central  portions  are  made  up  of  comparatively  large  and 
coarse  granular  bodies,  when  viewed  with  lower  powers  of  the  micro- 


234  DENTAL    PATHOLOGY    AND    PRACTICE. 

scope.     The  borders  of  this  tissue  are  intimately  connected  with  the 
fibrous  connective  tissue.     (See  Fig.  93,  C.) 

The  basis-substance  is  everywhere  scanty,  and  partly  hyaline,  partly 
finely  striated.  Higher  powers  reveal  a  surprising  variety  in  the  sizes 
and  shapes  of  these  bodies.  From  the  smallest  lump  (see  Fig.  96, 
L)  there  are  transitions  to  large  oblong  corpuscles,  mostly  arranged 
in  groups  and  clusters.  (See  Fig.  96,  M.)  The  shapes  vary  from 
small  globules  up  to  large  protoplasmic  masses,  flattening  one 
another  where  they  are  arranged  like  twins  or  triplets.  Similar  for- 
mations can  be  seen  in  almost  any  portion  of  normal  cartilage,  and 
such  groups  have  been  looked  upon  by  histologists  of  olden  times  as 
striking  examples  of  cell-division.  Now  we  are  aware  that  twin  for- 
mations are  visible  in  the  earliest  as  well  as  in  the  latest  formations  of 
this  tissue,  and  mean  merely  a  grouping  from  the  very  origin,  but  no 
division.  That  at  least  the  (comparatively  speaking)  active  tissue 
should  show  lively  division  is  beyond  comprehension.  Besides,  how 
could  the  dense  and  tough  basis -substance  yield  to  make  room  for 
the  rapid  growth  and  division  of  cells  ?  Since  the  fact  is  established 
that  the  basis-substance  of  hyaline  cartilage  is  traversed  by  living 
matter,  as  well  as  the  protoplasmic  bodies  themselves,  the  changes  in 
the  forms  and  sizes  of  the  corpuscles  are  easily  comprehended.  As 
the  borders  of  the  newly-formed  cartilage  exhibit  small  and  finely- 
granular  corpuscles,  we  are  justified  in  assuming  that  the  corpuscles 
in  this  situation  are  at  rest.  The  central  portions,  on  the  contrary, 
show  coarsely-granular  bodies  and  clusters  of  medullary  corpuscles, 
which  seems  to  indicate  that  the  latter  portion  Is  breaking  up  into 
embryonal  tissue  in  order  to  produce  fibrous  connective  tissue,  such 
as  arises  from  a  direct  breaking  up  of  bone-tissue.  Intermixed  with 
fully-developed  cartilage-corpuscles  we  meet  those  which  show  only 
a  central  nucleus  or  nucleolus,  while  the  protoplasm  is  extremely 
pale,  and  differs  from  the  surrounding  basis-substance  only  by  Its 
slightly  increased  refraction.  According  to  Spina,  these  forms  mean, 
a  gradual  change  of  cartilage-corpuscles  into  basis-substance,  a  con- 
clusion which  seems  to  be  well  founded. 

Basis-substance  originates  in  protoplasm,  and  may  return  to  the 
protoplasmic  state  at  any  time.  This  tissue  strongly  supports  the 
view  of  the  changeableness  of  protoplasm,  and  as  strongly  contra- 
dicts the  old-fashioned  ideas  of  the  stability  of  cells.  A  variety  in 
the  forms  of  cartilage-corpuscles,  as  we  have  just  described,  is  seen 
in  the  transitional  cartilaginous  tissue  known  as  ' '  provisional  callus' ' 
of  shaft-bones. 

6.  Bone-Tissue.  (See  Fig.  97.)  After  individual  teeth  have  been 
lost,  their  sockets,  in  time,  disappear,  and  after  all  the  teeth  are  gone 
the  entire  alveolar  process  fades  away.     This  change,  so  common,  is 


SENILE   ATROPHY    OF   THE   UPPER   JAW. 


235 


known  by  the  term  "absorption,"  but  we  are  not  satisfied  with  the 
idea  conveyed  by  this  expression,  for  it  is  evident  that  a  hard  tissue 
like  bone  cannot  be  disposed  of  with  so  Httle  ceremony.  It  would 
seem  more  reasonable  to  expect  that  it  must  first  be  reduced  to  its 
protoplasmic  condition,  which  as  such  is  more  readily  disposed  oC 

Fig.  97. 


Senilk  Changes  of  Bone  of  Upper  Jaw. 

£,  border  of  bone-tissue  jagged  and  showing  bay-like  excavations;  M,  bone-corpuscles 
broken  up  into  medullary  tissue ;  //,  enlarged  Haversian  canal ;  B,  bone-corpuscles  trans- 
formed  into  basis-substance.    Magnified  800  diameters. 

The  results  of  our  studies  in  this  case  fully  justify  us  in  assuming  that 
such  changes  do  take  place.  Both  the  cortical  and  the  spongy  por- 
tion are  much  reduced, — the  former,  in  some  places,  to  a  complete 
disappearance,  the  latter  by  a  diminution  of  the  bulk  of  its  trabec- 
ulae.  The  way  in  which  this  is  accomplished  is  twofold.  The  bone- 
tissue  is  attacked  first  upon  its  periphery,  through  the  attachment  of 


236  DENTAL    PATHOLOGY    AND    PRACTICE. 

the  periosteum,  and  second,  by  an  enlargement  and  new  formation 
of  Haversian  canals  in  a  previously  perfectly-formed  mass  of  bone. 
The  borders  are  corro'ded,  jagged,  and  amply  provided  with  bay-like 
excavations,  such  as  we  see  so  frequently  in  the  process  of  inflamma- 
tion of  bone.  The  bays  usually  contain  protoplasmic  bodies  of  vary- 
ing sizes  and  shapes,  but  we  have  nowhere  met  with  multinuclear 
bodies  or  giant-cells,  which  Kolliker  termed  in  a  rather  humoristic 
way  "  bone- breakers"  or  "osteoclasts."  The  origin  of  these  med- 
ullary corpuscles  is  occasionally  traceable  from  former  bone-corpus- 
cles that  have  been  deprived  of  their  surrounding  basis-substance. 
(See  Fig.  97,  E.) 

Since  in  one  connection  the  basis-substance  is,  though  infiltrated 
with  lime-salts,  just  as  viable  as  are  the  bone-corpuscles  themselves, 
we  can  readily  understand  that  after  a  dissolution  or  liquefaction  of 
the  basis-substance  protoplasmic  bodies  will  reappear.  The  next 
stage  is  the  elongation  of  the  medullary  corpuscles  into  spindles,  and 
thence  into  fibrous  basis-substance,'  with  a  simultaneous  new  forma- 
tion of  capillary  blood-vessels. 

The  new  formation  of  Haversian  canals  proceeds  in  exactly  the 
same  manner  as  in  osteitis,  although  on  a  much  smaller  scale.  First 
a  bone- corpuscle,  or  several  neighboring  ones,  become  enlarged  by 
a  liquefaction  of  the  surrounding  basis-substance.  Next  the  living 
matter  of  such  corpuscles  increases  in  glistening  homogeneous  lumps. 
Some  of  the  connecting  canaliculi  are  widened  into  broad  canals,  the 
tenants  of  which  increase  in  bulk.     (See  Fig.  97,  M.) 

Thus  protoplasmic  masses  appear  in  a  solid  basis-substance,  in  which, 
by  a  hollowing  out  of  the  living  matter,  new  capillaries  are  produced, 
as  noted  by  Heitzmann,  in  describing  the  process  of  osteitis,  in  1872. 
An  already-formed  Haversian  canal  is  widening  by  continual  melting 
down  or  dissolution  of  the  adjacent  basis-substance,  with  a  gradual 
reappearance  of  embryonal  or  medullary  corpuscles  (Fig.  97,  //),  the 
ultimate  destiny  of  which  seems  to  be  the  production  of  fibrous  con- 
nective tissue.  This  tissue  at  last  is  liquefied  into  protoplasm  in  the 
manner  before  described.  In  fact,  the  widened  medullary  spaces 
mostly  hold  such  protoplasm,  with  only  a  few  fat-globules. 

An  important  question  finds  solution  in  the  study  of  senile  bone, 
viz  :  that  of  interstitial  growth.  Most  modern  histologists  hold  the 
opinion  that  bone-tissue  grows  by  super-addition  from  without  by 
apposition.  A  few  writers,  however,  claim  that  bone  may  also  grow 
by  an  increase  of  the  basis-substance  between  the  already-formed 
bone-corpuscles,  which  view  seems  to  find  support  in  the  fact  that 
the  bone- corpuscles  in  old  animals  are  farther  apart  than  those  in 
the  young.  Our  studies  enable  us  to  account  for  this  apparent  inter- 
stitial growth  as  follows  :  It  is  a  fact  that  with  advancing  age  bone- 


SENILE   ATROPHY    OF   THE   UPPER   JAW.  237 

corpuscles  become  fewer  in  number,  the  reason  for  which  is  that 
many  of  them  are  transformed  into  basis-substance,  the  same  as 
Spina  has  claimed  that  cartilage- corpuscles  are.  Here  and  there  we 
meet  with  a  pale,  finely-granular  bone-corpuscle  without  any  vestige 
of  a  nucleus,  and  a  refraction  differing  but  slightly  from  that  of  the 
surrounding  basis-substance.     (See  Fig.  97,  B,^ 

Obviously  a  nucleated  bone-corpuscle  has  changed  into  a  finely- 
granular  protoplasmic  body,  which  means  an  approach  to  glue,  and 
subsequently  to  calcification.  In  looking  over  the  tissue  changes 
from  the  earliest  embryonal  life  to  the  approaching  physiological  end 
of  the  individual,  one  must  arrive  at  the  conclusion  that  there  is  not 
for  a  moment  absolute  rest  in  the  tissues.  Temporarily,  single  proto- 
plasmic bodies  may  make  their  appearance,  such  as  we  see  in  odonto- 
blasts and  ameloblasts.  Temporarily,  tissues  may  come  into  exist- 
ence, as  cartilage,  which  soon  afterward  are  lost,  or,  speaking  more 
correctly,  become  transformed  into  other  tissues.  So  long  as  life  lasts, 
protoplasm  and  the  tissues  sprung  therefrom  are  unstable. 

All  tissues  arise  from  protoplasm,  or  its  medullary  or  indifferent 
corpuscles,  and  all  tissues  return  to  this  emb'-yonal  or  medullary  state 
before  they  are  absorbed. 


INDEX. 


Absorption  of   roots    of   temporary 
teeth,  94. 

Abscesses,  treatment  of,  121,  128,  135. 

Acid  theory  of  decay,  73,  87,  89. 

Aconite  as  a  counter-irritant,  121. 

Age,  effect  of  on  the  human  organism, 
225. 

Alkaline  treatment  of  sensitive  den- 
tine, 106. 

Allen,  H.,  description  of  fifth  pair  of 
nerves,  143. 

Alveolar  abscess,  differential  diagnosis 
of,  124. 
treatment  of,  124. 

Alveolar  process,  absorption  of,  234. 

Amalgam  as  a  filling-material,  112. 

Ameloblasts  as  enamel-formers,  38. 
development  of,  20. 

Andrews,  R.  R.,  on  development  of 
dentine,  8. 

Anemia,  dental  operations  in,  190. 

Angioma,  206. 

Anomalous  relation  between  dentine 
and  enamel,  59. 

Antiphlogistin,  121. 

Antral  diseases,  diagnosis  and  treat- 
ment of,  127. 

Antrum,  function  of,  127. 
operation  for  gaining  entrance  to, 

133- 
Aphthous  stomatitis,  192. 
Approximal  cavities,  filling  of,  104. 
Arsenic  in  pulp-treatment,  114. 
Atkinson,  W.  H.,  on  alveolar  abscess, 

115- 
plugging  points,  103. 
Atrophy,  senile,  of  upper  jaw,  225. 
Automatic  mallet,  Abbott's,  no. 

Beale,  cell  theory  of,  5. 
Bell,  T.,  on  dental  caries,  86. 
Benign  tumors,  194. 
Blood-vessels,  senile  changes  of,  231. 
Bddecker,  C.  F.  W.,  on  development 
of  enamel,  18,  58,  70. 

on  function  of  odontoblasts,  8,  35. 
Bodecker's  enamel-fibers,  25. 
Bone,  development  of,  171. 

senile  changes  of,  234. 
Burnishing  points,  in. 
238 


Calculi,  abscesses  from,  135. 
Cancer,  bacilli  of,  195. 

varieties  of,  220. 
Canker  sores,  significance  of,  190. 

treatment  of,  192. 
Carcinoma,  220. 

Cartilage,  senile  changes  of,  233. 
Cavernous  angioma,  208. 
Cavities,  preparation  of,  105. 
Cell  theory,  exceptions  to,  23. 
Cement,  caries  of,  83. 
Cementum,  absorption  of,  96. 
Children's  teeth,  absorption  of  roots 
of,  94. 

treatment  of,  90. 
Climacteric,  influence  of  on  antral  dis- 
eases, 130. 
Cohnheim's    theory  of  tumors,    170, 

195- 
Creasote  in  pulp-treatment,  116. 

Dental  caries,  etiology  of,  57,  73. 
Dental  operations,  conditions  unfavor- 
able to,  I 87. 
Dentifrices,  antiseptic,  138,  139. 
Dentinal  canaliculi,  formation  of,  7. 
Dentinal  papilla,  development  of,  2. 
Dentine,  absorption  of,  99. 

caries  of,  77. 

odontoblasts  in  relation  to,  5. 

Ebner,  Prof.,  on  formation  of  dentine, 

38. 
Embryonal  malformation  of  teeth,  178. 
Enamel,  absorption  of,  loi. 

anomalies  of,  54,  59. 

asymmetry  of  in  the  growing  tooth, 
27. 

calcification  of,  26. 

caries  of,  74. 

congenital  defects  in,  46, 

deficient  calcification  of  without  pig- 
mentation, 65. 

development  of,  15,  58. 

granulation  of,  68. 

pigmentation  of,  66,  75. 

preparation     of    for    microscopical 
study,  72. 

sensitiveness  of,  163. 

stratification  of,  23,  61, 


INDEX. 


239 


Enamel  chisels  and  hatchets,  Abbott's, 
105. 

Enamel-organ,  development  of,  2,  16, 
26. 
myxomatous  structure  of,  56. 

Enamel-rods,  anomalous  arrangement 
of,  63. 
development  of,  17. 

Endothelia,  arrangement  of  in  angi- 
oma, 20S. 

Epitheliomata,  220. 

Epithelium,  senile  atrophy  of,  227. 

Epulis,  200. 

Epulis  sarcomatosa,  210. 

Escharotics  for  alveolar  abscess,  125. 

Facial  neuralgia,  causes  and  treat- 
ment of,  163. 

medicaments  for,  169. 
False  alveolar  abscess,  121,  124, 

treatment  of,  126. 
Fat-tissue,  development  of,  204. 
Fibril-cells,  8. 

identity  of  with  odontoblasts,  36. 
Fibroma,  200 
Fibro-myeloma,  213. 
Fibrous      connective      tissue,     senile 

changes  of,  229. 
Fifth  pair  of  nerves,  anatomy  of,  143. 

extreme  sensitiveness  of,  163. 

function  of,  156. 
First  permanent  molar,  removal    of, 

92- 

Fox,  J.,  on  dental  caries,  86. 

Fungous  growth  of  the  pulp,  treat- 
ment of,  117. 

Gangrene  of  the  teeth,  86. 

Gestation,  treatment  of  teeth  during, 
188. 

Giant-cell  sarcoma,  210. 

Giant-cells,  presence  of  in  benign 
tumors,  20  r. 

Gingivitis,  193. 

Globo-myeloma,  218. 

Gold  as  a  filling-material,  102. 

Granular  layer  of  dentine,  180. 

Granuloma  of  gum,  197. 

Gutta-percha  as  a  filling-material,  113. 

Gutta-percha  and  wax  in  pulp-treat- 
ment, 117. 

Handicap  tooth-powder,  138. 

Hart,  J.  I.,  on  living  matter  in  dentine, 

50. 
Heitzmann,    C,    on   development    of 

enamel,  18. 
on  protoplasmic  development,  6,  8, 

35,  70.  84. 
Herbst,  W.,  method  of  gold  filling, 

III. 
Highmore,  N.,  description  of  antrum, 

127. 
Hunter,  J.,  on  dental  caries,  85. 


Huxley  on  development  of  dentine, 

45- 
Hyaline    cartilage,    presence     of    in 

senile  jaw,  233. 
Hyperostosis  of  roots  of  teeth,  169. 

Inflammation,  effect  of  on  enamel, 

56,  86. 
Instruments  for  filling  teeth,  103,  104, 
105,  110,  112. 
sterilization  of,  189. 
Interglobular  spaces  in  dentine,  52. 
interprismatic  spaces  in  enamel,  60, 

68. 
Interstitial  growth  of  bone-tissue,  236. 
Interzonal  layer  of  dentine,  71,  182. 
lodin  in  antral  diseases,  132. 
Iron,  injury  to  teeth  by,  190. 

use  of  in  anemia,  190. 
Irregularities,   prevention   of   in   chil- 
dren's teeth,  93. 

Jacobi,  a.,  on  anomalies  of  enamel, 

54- 
Jaws,  senile  atrophy  of,  225. 
tumors  of,  193. 

Klein,  cell  theory  of,  5. 
Kolliker,  A.,  on  development  of  den- 
tine, 7. 
on  development  of  enamel,  16,  18. 

Lactation,  treatment  of  teeth  during, 

188. 
Leber  and  Rottenstein  on  dental  caries, 

87.  ... 

Lesser,  E.,  on  ccnneclion  of  hirsuties 

with  dental  anomalies,  55. 
Lipo-fibroma.  204. 
Living  matter  in  cementum,  172,  186. 

reticulum  of  in  dentine,  50,  70. 
Lobular  angioma,  206. 

Magitot,  E.,  on  dental  caries,  86. 
Magnesia,  preparations  of  for  sensitive 

dentine,  107. 
Main;    S.    A.,    case    of   hyperostosis, 

177- 
Malignant  tumors,  194. 
Mallet-pluggers,  Abbott's,  103. 
Malpositioned   teeth,   facial   neuralgia 

due  to,  165. 
Medullary  cancer,  223. 
Medullary  corpuscles  as  dentine-form- 
ers, 38. 
Mercurial  poisoning  as  a  cause  of  p>or- 

rhea,  137. 
Mercurial  stomatitis,  191. 
Mercury,  effect  of  on  the  periosteum, 

189. 
Mercury  bichlorid  as  an  antiseptic,  1 19, 

132. 
Mewborn,  J.   L.,  on  antral  diseases, 

129. 


240 


INDEX. 


Micro-organisms,  agency  of  in  dental 
caries,  73,  76,  78,  87. 

Morning  sickness  of  gestation,  treat- 
ment of,  188. 

Mother  cells  of  epithelioma,  222. 

Mouth,  inflammatory  conditions  of, 
191. 

Mouth  and  throat  spray,  140. 

Mucous  patches,  significance  of,  189. 

Myeloma,  210. 

Myxo-fibroma,  198. 

Myxoma,  196. 

Myxomatous  tissue,  formation  of,  199. 

Myxo-myeloma,  211. 

Napkins,  use  of  in  filling-operations, 
108.  I 

Neck-layers  in  enamel,  63. 
Nerves,  senile  changes  of,  232. 
Net-cell  sarcoma,  211. 
Non-occlusion,  neuralgia  from,  168. 

Odontoblasts  in  their  relation  to  de- 1 
veloping  dentine,  5,  35. 

Oral  mucosa,  senile  changes  of,  229. 

Osseous  union  of  teeth,  177. 

Osteitis,  distinction  of  from  dental 
caries,  88. 

Osteoclasts,  202,  236. 

Osteo-dentine,  180. 

Osteo-fibro-myeloma,  217. 

Osteomata,  174. 

Osteo-myeloma,  216. 

Oxychlorid  of  zinc  as  a  filling  for  pulp- 
less  teeth,  120,  126. 

Perforating   resorption   of   the  ce- 

mentum,  187. 
Periostitis,  aconite  in,  121. 

neuralgia  arising  from,  168. 
Pluggers,  hand,  no. 

hand-burnishing,  104. 
Primitive  dental  groove,  2. 
Protoplasm,    transformation    of    into 

basis- substance,  172. 
Provisional  callus  of  shaft-bones,  234. 
Ptyalism,  treatment  of,  191. 
Pulp-capping,  115. 

Pulp-exposure,  treatment  of,  91,  114. 
Pulpless  teeth,  facial  neuralgia  due  to, 
167, 

treatment  of,  118. 
Pulp-stones,  164. 
Pyorrhea  alveolaris,  136. 

Rachitis,    influence   of   on  develop- 
ment of  the  teeth,  29,  55. 
Rodent  ulcer,  223. 
Roots,  hyperostosis  of,  169. 
Rubber-dam,  objections  to,  108. 

Saliva,    control    of   in    filling-opera- 
tions, 107. 
Salivary  calculus,  136. 


Salivary  glands,  abscesses  in,  135. 

Saw  and  file  carriers,  112. 

Scalers,  varieties  ot,  141,  142. 

Schultze,  M. ,  transformation  theory  of, 
5,6. 

Secretion   theory   of  Virchovi^,   5,    16, 
84. 

Sections,  preparation  of  for  the  micro- 
scope, 28,  72. 

Sensitive  dentine,  treatment  of,  106. 

Spindle  myeloma,  219. 

Spontaneous  stomatitis,  191. 

Spray,  antral,  J32. 

mouth  and  throat,  140. 

Stellate  reticulum,  function  of,  15. 

Stomatitis,  varieties  and  treatment  of, 
191. 

Syphilis,  diagnosis  of,  189. 

Syringe  for  treatment  of  antral   dis- 
eases, 131. 
for  treatment  of  pulpless  teeth,  120. 

Tartar,  arrest  of  caries  by,  73. 

facial  neuralgia  from,  167. 

instruments  for  removal  of,  141,  142. 
Teeth,  caries  of,  57,  70. 

deciduous,  treatment  of,  90. 

development  of,  i. 

filling  of,  102. 

order  of  eruption,  90. 

osseous  union  of,  177. 

stage  of  development  of  at  birth, 
28. 
Tin  as  a  fifling-material,  112. 
Tissues,  rejuvenescence  of  in  old  age, 

233- 

varieties  of  in  the  animal  body,  193. 
Tomes,  J.,  on  dental  caries,  89. 

on  development  of  enamel-rods,  17, 
18. 

on  function  of  odontoblasts,  9. 
Tomes  processes,  24. 
Tooth-brush,  best  form  of,  138. 

local  disturbances  caused  by,  192. 
Transformation  theory  of  Schultze,  6. 
Tumors,  cause  of,  195. 

nomenclature  of,  194. 

Ulitis,  193. 

Vacuolation  of  the  endothelia,  210. 

Vaso-dentine,  183. 

Virchovi^,  secretion  theory  of,  5,  16,  84. 

Waldeyer,     F.,     on     formation     of 

enamel,  17. 
Wedging,  methods  of,  104. 
Wedi,  C,  on  dental  caries,  88. 
White  decay  of  teeth.  65. 
Wood  creasote  in  pulp-treatment,  116. 

Zinc  chlorid  as  an  escharotic,  125. 
Zinc   phosphate  as  a  filling-material, 
113- 


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